Every finding on record at Village of Lebanon

Based on observation, interview, record review, review of manufacturer's instructions for medication administration, and review of the facility policy, the facility failed to maintain a medication error rate of less than 5 percent (%). Three medication errors were observed during 27 medication error opportunities, for a medication error rate of 11.11%, which affected 2 (Resident #41 and Resident #47) of 3 residents observed during medication pass.Findings included: A facility policy titled, Medication Administration, revised 08/01/2025, indicated, 11. Review the MAR [Medication Administration Record] to identify medication to be administered. 12. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. 17. Administer medication as ordered in accordance with manufacturer specifications. 1. An admission Record indicated the facility admitted Resident #41 on 01/14/2015 and most recently readmitted the resident on 02/05/2024. According to the admission Record, the resident had a medical history that included diagnoses of type 2 diabetes mellitus without complications; generalized anxiety disorder; recurrent major depressive disorder, unspecified; bipolar disorder, unspecified; and insomnia, unspecified. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/09/2025, revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS revealed the resident had diagnoses that included diabetes mellitus, depression, bipolar disorder, and anxiety. Additionally, the MDS indicated Resident #41 had received insulin injections on each of the last seven days of the assessment look-back period and had received antianxiety medications, antidepressants, and hypnotic medications during the seven-day assessment look-back period. Resident #41's Care Plan Report included a focus area initiated on 02/20/2024 that the resident had the potential for hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar) related to diabetes. Interventions directed a nurse to give diabetes medications as ordered (revised on 05/16/2024). The care plan report also included a focus area that indicated Resident #41 received hypnotic medication related to insomnia (revised on 02/28/2024). Interventions directed staff to administer hypnotic medication as ordered (revised on 05/16/2024). An Order Summary Report, with physician's active orders effective for the timeframe ending 08/12/2025, indicated Resident #41 had orders for zolpidem tartrate (a sedative-hypnotic medication) oral tablet, 5 milligrams (mg) to be given one time a day for insomnia (order date 12/23/2024) and Humalog mix 75/25 subcutaneous suspension 100 units per milliliter (ml) for 40 units to be given after supper for diabetes mellitus (order date 04/04/2025). The manufacturer's instructions for the Humalog Kwik Pen injection, dated 2023, indicated, Prime before each injection. Priming your Pen means removing the air from the Needle and Cartridge that may collect during normal use and ensures that the Pen is working correctly. If you do not prime before each injection, you may get too much or too little insulin. An observation, beginning on 08/12/2025 at 4:00 PM, was made of Licensed Practical Nurse (LPN) #6 preparing medication for Resident #41. LPN #6 took a card of zolpidem tartrate oral tablet, 5 mg out of a locked narcotic drawer, removed a tablet from the blister pack, placed the tablet in the medication cup, and returned the zolpidem medication card to the narcotic drawer. LPN #6 then took the zolpidem tartrate card out again and removed another tablet from the medication card and placed the tablet in the medication cup. The surveyor stopped LPN #6 and stated the second tablet was supposed to be Xanax (an antianxiety medication). The nurse then turned the dial on the insulin pen to 40 units and gave the insulin into the resident's right lower abdomen. LPN #6 did not prime the insulin pen before dialing up the dose of insulin. LPN #6 was interviewed on 08/12/2025 at 4:29 PM. The LPN stated she had popped out two zolpidem tartrate and placed them in the medication cup because she was nervous. The LPN stated the manufacturer's instructions did not give directions to prime the pen before giving the insulin, and she stated she had not been taught to prime the pen at any time. LPN #6 stated the only time she primed the insulin pen was if she saw air in the insulin pen. Registered Nurse (RN) #4 was interviewed on 08/13/2025 at 2:48 PM. RN #4 functioned as the Staff Development Coordinator (SDC) for the facility. RN #4 stated nurses were taught to prime the insulin pens before each use and added priming the pen was important for the resident to receive an accurate amount of insulin and to expel any air from the pen. RN #4 stated she taught all nurses the six rights of medication administration, which included the right resident, right medication, right dose, right time, right route, and the right documentation. A telephone interview was held with the Consultant Pharmacist (CP) on 08/14/2025 at 2:07 PM. The CP stated priming an insulin pen was important before using the pen for the first time, but she was unsure about priming the insulin pen before subsequent uses. The CP stated she needed to review the manufacturer's instructions. The CP stated priming the insulin pen before the first use was important to make sure insulin was in the needle. She stated if the correct dosage of insulin was dialed on the pen, then Resident #41 should have received the correct dosage. The CP stated LPN #6 placed two zolpidem tartrate in the medication cup due to nerves. The CP stated she expected all nurses to follow the six rights of medication administration and pay more attention to what medications were placed in the medication cup for administration. The CP stated getting an extra zolpidem once may have made Resident #41 more sleepy than usual but would have had no harmful effects. The Director of Nursing (DON) was interviewed on 08/15/2025 at 12:35 PM. The DON stated when nurses gave medication, she expected them to follow the rights of medication administration including right resident, right time, right dose, and right medication. The DON stated she would have expected the nurse to check the medication label and the MAR before removing the second zolpidem into the medication cup. The DON stated LPN #6 was expected to prime the insulin pen before each use to make sure the correct dosage of insulin was given. The DON stated Resident #41 could have received too much insulin or not enough insulin. The DON stated she had spoken to LPN #6, who confirmed to her that she never primed the insulin pen even before using it for the first time. The Administrator was interviewed on 08/15/2025 at 1:09 PM and stated she expected the nurses to give the right medication in the right dosage to the right resident and follow any special instructions on the medication label. 2. An admission Record revealed the facility admitted Resident #47 on 01/01/2023. According to the admission Record, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) with exacerbation and acute and chronic respiratory failure. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated that the resident was able to hear without difficulty, had clear comprehension, and was able to understand verbal content. The MDS indicated the resident had a diagnosis of asthma, COPD, or chronic lung disease. Resident #47's Care Plan Report included a focus area revised on 02/08/2023 that indicated the resident had congestive heart failure and was at risk for complications. Interventions directed a nurse to administer inhalers (revised on 04/26/2024). A focus area, revised on 07/15/2025, revealed the resident had COPD and was at risk of developing complications. Interventions directed a nurse to give aerosol or bronchodilators as ordered and to monitor for side effects and effectiveness (initiated on 07/15/2025). An Order Summary Report for Resident #47, with physician's orders effective for the timeframe ending 08/13/2025, included an order for Trelegy Ellipta Inhalation Aerosol Powder Breath Activated (an inhaler that contained a steroid medication) 100-62.5-25 microgram (mcg) per actuation. The instructions were to take one puff orally one time a day for congestion related to COPD with exacerbation. The manufacturer's instructions for the Trelegy inhaler, revised 01/2019, indicated under the warnings and precautions section, Candida albicans [yeast infection or thrush] infection of the mouth and pharynx may occur. Monitor patients periodically. Advise the patient to rinse his/her mouth with water without swallowing after inhalation to help reduce the risk. An observation began on 08/13/2025 at 8:50 AM of Registered Nurse (RN) #5 preparing and administering medications to Resident #47. The label for the Trelegy inhaler revealed instructions to RINSE MOUTH & [and] SPIT AFTER EACH USE was documented on the label. The observation revealed that RN #5 handed the resident the Trelegy inhaler and instructed the resident on how to inhale to get the most benefit from the medication. After administration of the inhaler, RN #5 did not give Resident #47 instructions to rinse their mouth and spit out the water. RN #5 was interviewed on 08/13/2025 at 9:02 AM. RN #5 reviewed the label for the inhaler and acknowledged the label clearly gave instructions to rinse after each use. RN #5 stated this was to avoid the development of oral thrush. RN #5 confirmed she had not asked Resident #47 to rinse their mouth after the use of the inhaler. The RN stated she had been speaking to Resident #47 about asking the physician for a spacer (a device that makes the inhalation of medication more effective) and had forgotten to ask the resident to rinse. RN #4 was interviewed on 08/13/2025 at 2:48 PM. RN #4 was the Staff Development Coordinator (SDC) for the facility. She stated the nurses were taught to have residents rinse their mouth and to read the directions on the medication labels for specific instructions about individual inhalers. RN #4 stated rinsing after the use of an inhaler was important to decrease the risk of thrush in the resident's mouth. A telephone interview was held with the Consultant Pharmacist (CP) on 08/14/2025 at 2:07 PM. The CP stated rinsing after using inhalers that contained a steroid was important to prevent fungal infections and thrush. The CP stated that if rinsing after the use of an inhaler was required, the information was printed on the medication label. The Director of Nursing (DON) was interviewed on 08/15/2025 at 12:35 PM. The DON stated that when nurses were giving medication, she expected them to follow the rights of medication administration including the right resident, right time, right dose, and right medication. The DON stated that after an inhaler that contained a steroid was used, the resident's mouth should be rinsed. She stated that it was important to prevent oral thrush. The DON stated Resident #47 had not had any episodes of oral thrush. The DON stated that she had received a pharmacy recommendation to add instructions to rinse after use of an inhaler to each resident's Medication Administration Record (MAR) but had not completed the task. The Administrator was interviewed on 08/15/2025 at 1:09 PM and stated she expected the nurses to give the right medication in the right dosage to the right resident and follow any special instructions on the label.

Based on observation, interview, and facility policy review, the facility failed to ensure staff transported 1 (Resident #31) of 4 residents in their geriatric chair in a forward-facing position to promote dignity. Findings included: A facility policy titled, Promoting/Maintaining Resident Dignity, revised 10/01/2024, indicated, It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. An admission Record indicated the facility admitted Resident #31 on 03/14/2025. According to the admission Record, the resident had medical history that included diagnoses of dementia, anxiety disorder, adult failure to thrive, need for assistance with personal care, and major depressive disorder. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/20/2025, revealed Resident #31 had a Brief Interview for Mental Status (BIMS) score of 7, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident was dependent on staff for transfers. Resident #31's Care Plan Report included a focus area revised on 06/24/2025 that indicated the resident had an activities of daily living (ADL) self-care performance deficit related to dementia. Interventions initiated 06/24/2025 directed staff to utilize a geriatric (Geri) chair when the resident was out of bed. An observation on 08/11/2025 at 12:40 PM revealed Certified Nursing Assistant (CNA) #1 transported Resident #31 from the dining room in a rear facing position in a Geri chair. During an interview on 08/11/2025 at 1:20 PM, CNA #1 stated that transporting a resident in a rear facing position could be disrespectful and go against the resident's dignity. CNA #1 stated she transported the resident out of habit and she knew better than to pull any resident in a rear facing position. CNA #1 stated she had been trained to transport all residents in a forward-facing position. An attempt was made to interview Resident #31 on 08/11/2025 at 1:30 PM, but the resident was non-interviewable. During an interview on 08/12/2025 at 1:25 PM, CNA #2 stated that to transport a resident in their wheelchair or Geri chair, they should always be transported in a forward motion. She that that otherwise it would be a dignity issue for the resident. During an interview on 08/15/2025 at 11:35 AM, the Director of Nursing (DON) stated she expected staff to always transport the residents in a forward-facing position to promote dignity. During an interview on 08/15/2025 at 12:55 PM, the Administrator expected staff to transport residents in a forward-facing position because it could be a dignity issue for the resident.

Based on observation, interview, review of facility records, and policy review, the facility failed to provide incontinence care in such a manner as to reduce the risk of a urinary tract infection for 1 (Resident #47) of 2 residents whose incontinence care was observed.Findings included: A facility policy titled, Perineal Care, revised 10/01/2024, indicated, If perineum is grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. A. Cleanse buttocks and anus, front to back; vagina to anus in females, scrotum to anus in males, using a separate washcloth or wipes. An admission Record revealed the facility admitted Resident #47 on 01/01/2023. According to the admission Record, the resident had a medical history that included urinary tract infection, Stage 4 (severe) chronic kidney disease, chronic systolic (congestive) heart failure, and unspecified cardiomyopathy. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/05/2025, revealed Resident #47 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident was dependent on staff for toileting hygiene. The MDS revealed Resident #47 was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS indicated Resident #47 had a urinary tract infection within the previous 30 days and had taken an antibiotic. Resident #47's Care Plan Report included a focus area initiated 01/30/2024 that indicated Resident #47 had a history of recurrent urinary tract infections and was at risk for complications. Interventions directed staff to perform incontinence care with each incontinence episode (initiated 01/30/2024). A urology consultant note dated 07/03/2025 revealed a facility certified nursing assistant (CNA) present for the appointment and Resident #47 informed the urologist that the resident keeps a UTI [urinary tract infection]. The note indicated the CNA informed the urologist that when the resident had a UTI, the resident's urine became almost brown and was foul smelling. The note indicated under Plan details that Resident #47 was being seen for urinary hesitancy, incontinence, and possible incomplete bladder emptying. The note indicated the resident had been referred to the urologist when the UTIs became more frequent. The note also revealed a cystoscopy (a medical procedure to examine the bladder) that had been completed in 2023 that indicated Resident #47 retained debris in the bladder. Review of a note from Resident #47's primary care physician (PCP), dated 07/25/2025, revealed the resident had acute recurrent cystitis (a type of UTI caused by a bacterial infection). The note indicated Resident #47 had a neurogenic bladder (a bladder condition caused by nerve damage) with persistent and recurrent pyuria (a condition where the urine contains high levels of white blood cells or infection) requiring systemic antibiotics. The note indicated intermittent catheterization had been discontinued at the resident's request. The note indicated Resident #47 had acute recurrent cystitis without hematuria (blood in the urine) secondary to incomplete bladder emptying and neurogenic bladder secondary to a stroke that influenced secondary, recurrent, and frequent UTIs. Resident #47 was interviewed on 08/11/2025 at 12:55 PM and stated they currently had a UTI, and they had problems with recurrent UTIs. The resident stated they had a bowel movement (BM), and the BM had oozed out of the brief. Resident #47 stated they were unsure if staff were providing adequate care after incontinence. At 12:59 PM, Resident #47 activated the call light. The resident stated the BM had occurred during the lunch meal, but they had not called for anyone to change them. The Administrator answered the resident's call light and responded she would find someone to assist the resident. An observation began on 08/11/2025 of CNA #2 and CNA #3 assisting Resident #47 with incontinence care. The resident had a large amount of BM covering them. CNA #2 was observed wiping the resident from back to front as she tried to remove the BM from the resident. CNA #2 was stopped and stated she had been taught to always wipe from front to back and added she was aware she had wiped Resident #47 from back to front. CNA #2 then told Resident #47 that may be the reason the resident had so many UTIs. CNA #2 stated she was aware that cleaning the resident from back to front may introduce bacteria into the resident's urinary system but stated she had just been trying to get the BM off the resident. Registered Nurse (RN) #4 was interviewed on 08/13/2025 at 2:48 PM. RN #4 functioned as the Staff Development Coordinator (SDC) and the facility's Infection Preventionist (IP). RN #4 stated the CNAs were taught to wipe residents from front to back when providing incontinence care to prevent the introduction of bacteria into the urinary tract system. The RN stated UTIs caused by Escherichia coli (E. coli - a type of bacteria) was caused when feces was introduced into the urinary tract system during incontinence care. RN #4 stated she was unaware that Resident #47's recent UTIs had been caused by E. coli. RN #4 stated Resident #47's PCP had stated that Resident #47 was colonized and would continue to have UTIs due to the chronicity of the resident's diseases. RN #5, who was assigned to care for Resident #47, was interviewed on 08/14/2025 at 10:37 AM. RN #5 stated E. coli UTIs were caused from fecal matter introduced into the urinary tract system due to poor incontinence care. RN #5 stated Resident #47 had frequent UTIs, was on a fluid restriction, and was followed by a urologist. RN #5 stated Resident #47 had a diagnosis of neurogenic bladder that held urine. RN #5 stated that during incontinence care, the resident should be cleaned from front to back to minimize the risk of introducing bacteria into the resident's urethra and causing a UTI. The Director of Nursing (DON) was interviewed on 08/15/2025 at 12:26 PM. The DON stated that when the CNA provided perineal care, the CNA should clean the residents front to back. The DON stated the procedure was important to avoid introducing bacteria into the urinary system. The DON stated wiping the resident from back to front would introduce E. coli into the urinary system. The DON stated Resident #47's PCP had told her the resident's bladder did not empty completely, and the resident was colonized with bacteria. The DON stated other contributing factors included the resident used powder and had declined the in-and-out catheterization recommended by the physician. The Administrator was interviewed on 08/15/2025 at 1:10 PM and stated she expected the nurses and nursing assistants to follow the facility policy when providing incontinence care to residents so that UTIs may be avoided.Resident #47's PCP was unavailable for interview due to a medical procedure.

Based on observation, interview, and facility policy review, the facility failed to ensure 1 of 2 medication carts were locked when unsupervised. Findings included: A facility policy titled, Controlled Substance Administration & Accountability, revised on 06/01/2025, indicated, It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. An observation on 08/12/2025 from 3:18 PM to 3:26 PM revealed an unlocked/unsupervised medication cart outside room [ROOM NUMBER] with no staff present. During the observation, the nurse came out of a resident's room (the door was closed) and walked past the unlocked cart and went on to the nursing station. Registered Nurse (RN) #7 locked the cart when she returned at 3:26 PM. During an interview on 08/12/2025 at 3:28 PM, RN #7 stated she knew better than to leave the medication cart unlocked. RN #7 stated the risk of leaving carts unlocked/unsupervised was because someone, including any wandering residents, could get into the medication carts and get medications that did not belong to them. RN #7 stated it was no excuse, but she was in a resident's room providing a breathing treatment to a resident. RN #7 stated the cart was not in her line of sight when she was in the resident's room. During an additional observation on 08/12/2025 at 4:26 PM to 4:32 PM, the same medication cart was observed again to be unlocked and unsupervised. During this observation, no residents or staff were observed near the unlocked cart. During this observation, the location of the nurse was not known until the nurse came out of a resident's door into the hallway. The nurse came to the unlocked cart at that time and locked the medication cart. During an interview on 08/12/2025 at 4:32 PM, RN #7 stated she had no excuse why she had left the cart unlocked and unsupervised. She said it was a bad habit. She knew better, and she had received training on the importance of keeping medications safe and under locked carts. RN #7 stated that the risk of an unlocked cart was that a resident or visitor could get into the cart and get into the medication. RN #7 stated that both times the carts had been found to be unlocked they were not within her line of sight, and the carts were not supervised by any other staff. During an observation on 08/15/2025 from 10:48 AM to 10:53 AM, one medication cart was found to be unlocked/unsupervised outside of room [ROOM NUMBER]. During this observation, no residents or staff were present. LPN #8 was behind a resident's closed door at that time of this observation and returned to the unlocked cart and locked the cart. During an interview on 08/15/2025 at 10:55 AM, Licensed Practical Nurse (LPN) #8 stated she knew better than to leave the cart unlocked/unsupervised. LPN #8 stated the risk was someone like a resident, visitor, or even staff could get into the unlocked cart and have access to the residents' medications. LPN #8 stated she knew better and had been previously in-serviced on the importance of locking the medication carts. During an interview on 08/15/2025 at 11:35 AM, the Director of Nursing (DON) stated she expected the staff to keep the medication carts locked at all times. The DON stated the risk of unlocked/unsupervised medication carts was residents, visitors, or other staff getting into the carts. During an interview on 08/15/2025 at 12:55 PM, the Administrator stated she expected staff to keep the medications safe at all times.

Based on observation, interview, record review, facility policy review, and review of the facility investigation, it was determined the facility failed to ensure residents were free from abuse for one (1) of twenty (20) sampled residents (Resident #7). On 04/11/2021, Licensed Practical Nurse (LPN) #6 was overheard by State Registered Nurse Aide (SRNA) #1 and SRNA #3, state she would smack Resident #7 in the face if he/she didn't calm down. Based on validation of the Quality Assurance (QA) Plan, the State Survey Agency determined the deficient practice represented past non-compliance, as it was identified and corrected regarding protecting residents from abuse, prior to initiation of the investigation by the State Survey Agency. The findings include: Review of facility policy, titled, Abuse, last revised 02/13/2019, revealed the facility would prohibit abuse, mistreatment, neglect, misappropriation of resident property and exploitation for all residents. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal Abuse was the use of oral, written, or gestured language that willfully included disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. The policy further revealed the facility would take appropriate actions to prevent abuse, and the facility would report any allegation of abuse immediately to the charge nurse on duty and the Director of Nursing or Facility Administrator, or to another nurse manager or licensed nurse who would ensure the alleged perpetrator immediately left the facility. Review of Resident #7's medical record revealed the facility admitted the resident on 02/18/2019 with diagnoses which included Alzheimer's Disease, Bradycardia, Major Depressive Disorder, Anxiety Disorder, Cardiac arrhythmia unspecified, Atherosclerotic Heart Disease of native coronary artery without angina pectoris. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/03/2022, revealed the facility assessed Resident #7 as having a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen (15) indicating severe cognitive impairment. Further review of the MDS Assessment, revealed the facility assessed the resident as exhibiting behaviors one to three (1- 3) days a week. including delusions, physical behavioral symptoms, and verbal behavioral symptoms, all of which were directed toward others. Review of the facility Long Term Care Facility-Self Reported Incident Form/Combined Report, revealed an alleged incident of verbal abuse occurred on 04/11/2021 at 1:20 PM. Per the allegation, LPN #6 stated to Resident #7, she would smack {him/her} in the face if {he/she} didn't calm down. The Administrator was informed of the allegation on 04/11/2021 at approximately 2:00 PM. Further review revealed LPN #6 was terminated from the facility on 04/16/2021. Review of the facility Investigation, dated 04/11/2021, signed by the Administrator, revealed an incident of verbal abuse related to Resident #7 allegedly occurred on 04/11/2021 at 1:20 PM, and the incident was reported on 04/11/2021 at approximately 1:45 PM, to LPN #7. Per the allegation, SRNA #1 and SRNA #3 informed LPN #7, they had witnessed LPN #6 tell Resident #7, she would smack him/her in the face if he/she didn't calm down. Additional review revealed an investigation was immediately initiated and resident skin assessments were initiated on 04/11/2021. Further, LPN #6 was suspended on 04/12/2021 from the facility pending investigation. LPN #6 was terminated on 04/16/2021 as the facility substantiated the allegation. Review of Resident #7's Progress note, on 04/12/2021 at 8:25 AM, revealed Resident #7's Responsible Party (RP) and Physician were notified of the incident on 04/12/2021 . Both parties were informed of the investigative process and procedures and contact information was given to both parties for additional questions or concerns. Review of Resident #7's Skin assessment, completed on 04/12/2021, after the incident was reported, revealed no evidence of injury and no other issues or concerns. Observation of Resident #7 on 04/19/2022 at 3:47 PM, revealed the resident was lying in bed fully dressed with call light in reach. No skin injuries were observed. Interview was attempted with the resident; however, he/she was non-interviewable. Review of SRNA #1's written Statement, dated 04/11/2021, revealed Resident #7 was being combative as they were trying to return the resident to his/her room for declamation. LPN #6 came from behind the nurse's station to assist SRNA #1 as SRNA #3 retrieved toileting supplies from the supply room. Resident #7 was attempting to smack LPN #6, when LPN #6 stated, I will smack you in the mouth. Interview with SRNA #1, on 04/21/2022 at 2:16 PM, revealed although the incident took place over a year ago, she remembered the day in question. She stated Resident #7 was agitated and being combative. Per interview, SRNA #1 was attempting to return Resident #7 to his/her room for one on one (1:1) activities and personal care to assist in de-escalating the resident. SRNA #1 stated Resident #7 was swatting at LPN #6 as she was attempting to assist with the resident. Per interview, LPN #6 screamed in the resident's face that she would smack him/her in the mouth. Further interview revealed SRNA #1 and SRNA # 7 then reported the incident to LPN #6 and left written statements under the Administrator's door at the end of their shift. Review of SRNA #3's written Statement dated 04/11/2021, revealed Resident #7 was combative and grabbing at the nurse's cart. SRNA #3 was retrieving items to provide peri-care for Resident #7 from the supply room. As she entered the supply room she heard LPN #6 state, I'll slap you in the mouth. SRNA #3 and SRNA #1 then took Resident #7 to his/her room and provided care. Interview with SRNA #3, on 04/21/2022 at 1:45 PM, revealed on 04/11/2021, SRNA #3 was retrieving supplies from the storage room when she heard Resident #7 state, I am going to slap you, to LPN #6. SRNA #3 stated she then heard LPN #6 state, I'll slap you back. SRNA #3 further stated she did not witness any physical abuse, but the nurse and resident were just threatening to slap one another. Further interview revealed afterwards she (SRNA #3) assisted SRNA #1 to transfer Resident #7 back to his/her room and then immediately informed LPN #7. Review of LPN #6's written Statement, dated 04/12/2021, revealed on 04/11/2021 Resident #7 was verbally and physically aggressive towards staff while also exhibiting exit seeking behaviors. Resident #7 stated, I will smack you. Further review revealed the resident was then returned to his/her room by SRNA #1 and SRNA #3 for redirection and personal care. Interview with LPN #6 could not be completed. Multiple attempts were made to contact LPN #6 on 04/19/22-04/21/2022, via phone and messages were left. Record review revealed LPN #6 was terminated by the facility on 04/16/2021 via telephone with the Administrator and Human Resources present. Interview with LPN #7, on 04/21/2022 at 1:20 PM, revealed she was informed by SRNA #1 and SRNA # 3, that LPN #6 had screamed in Resident #7's face, I'll smack you back. LPN #7 stated she immediately contacted the Administrator who instructed her to escort LPN #6 to the timeclock and out of the building. Interview with the Social Services Director, on 04/21/2022 at 2:40 PM, revealed a full investigation into the incident was completed. She stated during the investigation she was responsible for assisting with interviewing the interviewable residents related to abuse, and no concerns or issues were noted at that time. Interview with Director of Nursing (DON) #5, on 04/21/2022 at 5:10 PM, revealed she was not there the day of the incident; however, she was there the following day. DON #5 stated the investigation was started immediately after the Administrator was made aware of the allegation on 04/11/2021. Further, she could not recall any prior instances of grievances or abuse allegations for LPN #6. She recalled the facility substantiated the allegation involving Resident #7, and LPN #6 was terminated. , Review of the Administrators written Statement, dated 04/12/2021, revealed the incident was reported to her on 04/11/2021 by LPN #7. Immediate action was taken and LPN #6 was escorted out of the building pending investigation findings. She instructed LPN #7 to begin the investigation and to complete skin assessments. Further review revealed staff training and re-education were initiated. Interview with the Administrator, on 04/21/2022 at 5:45 PM, revealed she was informed on 04/11/2021, by LPN #7, of an allegation of abuse involving Resident #7 and LPN #6. Per interview, SRNA #1 and SRNA #3 had informed LPN #7, that LPN #6 used harsh tones and threatened to smack Resident #7 in the mouth. The Administrator stated she instructed LPN #7 to remove LPN #6 from all resident care and escort her to the timeclock and out of the building pending investigation results. She further stated she confirmed with staff that the resident was free of harm and away from potential abuse. Continued interview revealed she instructed staff on 04/11/2021 to begin the investigation and to complete skin assessments on residents who were not interviewable. Further, residents who were interviewable were interviewed, as well as staff were interviewed during the course of the investigation. Additional interview with the Administrator, revealed the investigation was completed on 04/16/2021 and the Kentucky Board of Nursing (KBN) was notified of the allegation and investigative findings. Per interview, the Administrator and Human Resources terminated LPN #6 via telephone on 04/16/2021 for abuse. *** The facility implemented the following actions to correct the deficient practice: 1. Record review revealed LPN #6 was suspended on 04/11/2021, immediately after the incident was reported to the Administrator on 04/11/2021. 2. Interviews with interviewable residents (BIMS of eight {8}) and above were conducted on 04/12/2021 by the Social Services Director (SSD) related to verbal and physical abuse with no concerns identified. 3. Skin assessments were conducted by the licensed nurses on non-interviewable residents (BIMS scores below eight {8}) on 04/11/2021 and 04/12/2021, for signs of abuse with no concerns identified. 4. Interviews with all staff was conducted 04/12/21 through 04/16/2021, by the Administrator and Staff Development Nurse, to determine if anyone had knowledge of abuse in the facility with no concerns identified. 5. Facility wide abuse education and retraining was initiated. Abuse education and post- tests were provided to all staff 04/13/2021- through 04/19/2021, by the Administrator and Staff Development Coordinator. 6. Staff Kindly Audits were conducted on ten percent (10%) of the residents weekly X four (4) weeks, then quarterly with MDS assessment. MDS Kindly Audits to be presented to Quality Assurance Process Improvement (QAPI) on a quarterly basis. 7. A Quality Assurance Process Improvement (QAPI) meeting was held on 04/12/2021 to discuss the incident. Following the Staff Kindly Audits, Quality Assurance Performance Improvement (QAPI) meetings will be held quarterly. 8. A Corporate Compliance Officer provided the Kentucky Board of Nursing a copy of the investigative findings regarding LPN #6 per regulations. **The State Survey Agency validated the corrective action taken by the facility as follows 1. Review of LPN #6's personnel record, revealed she was suspended on 04/11/20201 and terminated via telephone on 04/16/2021 by the Administrator and Human Resources. 2. Review of interview logs revealed all residents were interviewed on 04/12/2021 by the Social Services Director (SSD), about the care they received in the facility, and asked if they had ever been abused with no concerns identified or noted. 3. Review of resident skin assessment sheets, dated 04/11/2021 and 04/12/2021, revealed all non-interviewable residents (residents with a BIMS score of below eight (8) were observed for signs of abuse with no concerns identified or noted. 4. Review of questionnaires revealed all staff were interviewed on 04/12/2021 through 04/16/2021 to determine if the staff had ever witnessed a staff member verbally or physically abusing a resident. Staff were also questioned regarding reporting of abuse. Interviews on 04/21/2022 with SRNA #2 at 1:18 PM; SRNA #3 at 1:45 PM; LPN #4 at 2:00 PM; SRNA #1 at 2:16 PM; SRNA #4 at 2:38 PM; LPN #3 at 3:37 PM; Interim DON at 5:10 PM, and Administrator at 5:45 PM, revealed they were interviewed related to knowledge of the incident that occurred on 04/11/2021 as well as what to do if abuse was seen or suspected. 5. Review of an Abuse education sign in sheet revealed education was provided on 04/12/2021 through 04/19/2021 which reviewed the Abuse Prohibition policy and reporting expectations. Additional review revealed staff completed post- tests related to the education provided by the Administrator and Staff Development Nurse. 6. Review of the Log book, revealed Staff Kindly Audits were conducted on ten percent (10%) of the residents weekly X four (4) weeks, then monthly X two (2) weeks, then quarterly with MDS assessment. 7. Review of QAPI minutes for 04/12/2021, revealed a meeting was held to discuss the allegation of abuse. Per the discussion, going forward QAPI meetings to be held quarterly to discuss MDS Staff Kindly Audit results and recommendations. 8. Review of cover sheet sent to the Kentucky Board of Nursing Investigation on 04/16/2021, revealed full investigation attached with results. 45113

Based on observation, interview, record review and review of facility policy, it was determined the facility failed to have an effective infection control program to prevent the spread of infection for two (2) of twenty (20) sampled residents (Resident #9 and #37). Nursing staff was observed to touch Resident #9 and #37's medications with bare hands prior to administration on 04/21/2022. The findings include: Review of the facility policy, titled, Medication Administration Infection Control Standards of Practice, undated, revealed the facility staff would provide safe medication administration to residents. However, the policy did not address the touching of resident's medications with bare hands. Observation of medication administration for Resident #9, on 04/20/2022 at 8:28 AM, revealed Registered Nurse (RN) #1 prepared Aspirin 81 milligram (mg) tablet (pain reliever, fever reducer), Losartan 50 mg tablet (medication used to treat hypertension), Metoprolol 25 mg tablet (medication to treat hypertension), and Vitamin B 12 500 microgram (mcg) tablet by removing the medications from the medication cards into her bare hand, then placing the medications into a medication cup for administration. RN #1 then proceeded to administer the medications to Resident #9 with applesauce. Observation of medication administration for Resident #37, on 04/20/2022 at 9:13 AM, revealed Licensed Practical Nurse (LPN) #1 prepared Tylenol 650 mg tablet (pain reliever and fever reducer), Atenolol 125 mg tablet (medication to treat hypertension), two (2)Crantabs 250 mg tablets, Eliquis 5 mg tablet (medications to prevent blood clots), Folic Acid 400 mcg tablet, Januvia 25 mg tablet (medication to treat Diabetes Mellitus), and Sertraline 25 mg tablet (antidepressant), by removing the medications from the medication cards into her bare hand, then placing the medications into a medication cup. The nurse then crushed the medications and administered them in applesauce to Resident #37. Interview with RN #1 on 04/21/2022 at 10:12 AM revealed the nurse was unaware she should not touch residents' medications with bare hands after the medications had been removed from packages. However, she stated touching the medications could potentially be an infection control issue. Interview with LPN #1, on 04/21/2022 at 1:29 PM, revealed the nurse was unaware she should not touch the residents' medications with bare hands when removing the medications from the packages. However, she stated she could see how touching the pills with her hands could be an infection control issue. Interview with the Director of Nursing (DON) on 04/21/2022 at 4:38 PM, revealed she was unaware nurses were touching residents' medications with their hands after opening the medication packages. Per interview, she had performed medications audits in the past and had not identified any problems. Further interview revealed touching the medications with bare hands could potentially spread germs to the resident and cause illness/infection. Interview with the Administrator, on 04/21/2022 at 5:19 PM, revealed she relied on the DON to monitor medication administration. Further, nurses were not to touch resident medications with bare hands because it was a potential infection control issue and could cause residents to become sick.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure one (1) staff member who was unvaccinated for COVID-19 due to a religious exemption, wore the required mask when providing care to residents. Observation on 04/21/2022, revealed LPN #2, who was unvaccinated for COVID-19, and had a religious exemption was wearing a blue medical mask. The findings include: Review of the facility policy titled, Employee COVID-19 Vaccinations, reviewed/revised 04/2022, revealed the facility would implement additional precautions to mitigate the transmission and spread of COVID-19 for all staff who were not fully vaccinated (i,e., had not completed primary series yet, had a pending or granted religious/medical exemption, or vaccine was delayed for a certain reason, etc.) (CMS term) or up to date (CDC term) for COVID-19. (Facility precautions/mitigation actions to be taken, may include, but not limited to i.e., masking, social distancing, reassignment, weekly testing, use of N95 or higher-level respirator, etc.) Review of the listing of unvaccinated staff revealed Licensed Practical Nurse (LPN) #2 as unvaccinated. Observation on 04/21/2022 at 7:19 AM, of LPN #2, revealed she was wearing a blue medical mask. Interview with LPN #2, on 04/21/2022 at 7:19 AM, revealed she was not vaccinated, but had a religious exemption. She stated she was supposed to be wearing a N95 mask. However, she stated she was unable to wear a N95 mask due to fungus in her blood, although she had not been medically diagnosed . She further stated she told the Director of Nursing (DON)/Infection Control Nurse and the Administrator, and was instructed to make sure she wore a blue mask. Interview with the DON, who was also the Infection Control Nurse, on 04/21/2022 at 4:30 PM, revealed the facility required unvaccinated staff to wear the N95 mask and if staff could not wear the N95 mask, she would question the staff member as to the medical reason. Per interview, she was unaware LPN #2 who was unvaccinated, was not wearing a N95 mask. She stated, according to policy, LPN #2 should not be working if she could not wear the N95 mask. Interview with the Administrator, on 04/21/2022 5:19 PM, revealed it was her expectation for unvaccinated staff to wear the correct mask. She stated LPN #2 did tell her she had been wearing a regular blue medical mask because of a medical reason, but LPN #2 had not provided a medical excuse. Further interview revealed when LPN #2 contacted her on 04/20/2022, stating she would be working on 04/21/2022 and would not be able to wear the N95 mask, she did advise LPN #2 just to wear her blue medical mask instead of the N95. The Administrator stated she thought it would be okay as long as the nurse wore a mask.

Based on observation, interview, record review and a review of facility policies, it was determined the facility failed to provide privacy/dignity during medication administration for one (1) of twenty (20) sampled residents (Resident #9). Staff was observed to administer eye drops medication to Resident #9 while the resident was seated in the day room area with six (6) other residents. The findings include: Review of the facility policy titled, Resident's Rights-Federal Law, dated October 2007, revealed the residents had the right to personal privacy and confidentiality to include medical treatment. Review of the facility policy titled, Medication Administration General Guidelines for the Administration of Medications number 6.2, undated. revealed medications were supposed to be administered at the resident's bedside and if administration would expose the resident's skin, the curtain would be drawn for privacy. Review of Resident #9's medical record revealed the facility admitted the resident on 05/17/2021 with diagnoses including Alzheimer's Disease, and Glaucoma. Review of the Quarterly Minimum Data Set (MDS) Assessment, dated 02/10/2022, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15) indicating severe cognitive impairment. Review of current Physician's orders, revealed orders for Combigan Solution eye drops (a medication to treat glaucoma) one (1) drop instilled in each eye twice daily. Observation of medication administration for Resident #9, conducted on 04/20/2022 at 8:28 AM, revealed Registered Nurse (RN) #1 administered Combigan Solution eye drops to the resident while he/she was sitting in a chair in the day room in view of six (6) other residents. Interview with RN #1, on 04/21/2022 at 10:12 AM, revealed she was unaware administering the eye drops to Resident #9 when the resident was in the day room with other residents was a dignity/privacy issue for the resident. Interview with the Director of Nursing (DON), on 04/21/2022 at 4:38 PM, revealed she was unaware eye drops were being administered to Resident #9 in the day room which could be a dignity or privacy issue. She stated the eye drops should be administered to residents in the privacy of the resident's room and not in front of other residents. Interview with the Administrator, on 04/21/2022 at 5:19 PM, revealed she monitored the treatment of residents daily and was unaware of staff administering eye drops to Resident #9 in the day room. According to the Administrator, performing treatments in view of others could be a privacy/dignity issue.

Based on observation, interview, and review of facility policy, it was determined the facility failed to ensure all drugs and biologicals were stored in locked compartments for one (1) of three (3) facility medication carts. Observation on 04/19/2022, revealed the South hall medication cart was observed to be unlocked and unattended. The findings include: Review of the facility Medication Administration General Guidelines for the Administration of Medications policy number 6.2, undated, revealed the Nurse or Certified Medication Aide would ensure the medication cart was locked any time the cart was out of direct line of vision. Observation of the South hall medication cart, on 04/19/2022 at 5:10 PM, revealed the cart was fifteen(15) feet from the nurse's station and was unlocked with no staff present. Further observation revealed Registered Nurse (RN) #1 came to the cart at 5:20 PM and then walked away from the cart, leaving the cart unlocked. Further observation revealed at 5:23 PM, RN #1 returned to the cart and locked the cart. No wondering residents were identified, and no residents were observed in the hallway at the time the cart was unlocked. Interview with Registered Nurse (RN) #1, on 04/21/2022 at 10:12 AM, revealed the nurse forgot to lock the medication cart by mistake. The RN stated the carts were supposed to be locked when they were left unattended to ensure security of the medications. Interview with the Director of Nursing (DON), on 04/21/2022 at 4:38 PM, revealed staff should lock the medication cart if the cart was out of direct line of sight or had to be left unattended. According to the DON, she monitored the medication carts when she was on the floor making rounds to ensure they were locked and had not identified any recent concerns with staff leaving the carts unlocked. Interview with the Administrator, on 04/21/2022 at 5:19 PM, revealed she was not aware RN #1 had not locked the medication cart and had left the cart unattended on the South hall on 04/19/2022. According to the Administrator, the medication carts were to be locked when not in use by staff because unsecured medication carts could be a potential accident hazard for residents and a potential security risk for the medications.

Based on observation, interview, record review, review of a facility investigation, and review of facility policies and the User/Service Manual for Devices and Side Rails it was determined the facility failed to ensure bed rails were safe for three (3) of three (3) residents (Residents #1, #2, and #3). The facility failed to attempt alternate approaches prior to side rail usage as required by the facility's policy, failed to assess Resident #1's risk for entrapment due to leaning/scooting to the right side of the bed/bed rail, and failed to review the risks and benefits with the resident's representative and obtain informed consent prior to utilizing side rails for Resident #1. On [DATE], the facility completed an assessment and determined the resident would benefit from one-fourth length bed rails. In addition, the resident had a physician's orders [REDACTED]. However, the facility utilized one-half length bed rails for Resident #1. On [DATE], staff found Resident #1 hanging off the right side of the bed with the resident's neck on the bed rail and no signs of life. In addition, Residents #2 and #3 were assessed to require and had physician's orders [REDACTED]. However, observation revealed the residents were utilizing one-half length bed rails. Further, review of the facility's policy and User's Manual for the beds/bed rails revealed monthly inspections of the bed/rails were required. However, the facility failed to conduct monthly inspections of all beds with bed rails and was only conducting safety inspections of each bed every four (4) months. The facility's failure to ensure bed rails were assessed and utilized per physician order [REDACTED]. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled Proper Use of Side Rails, revised [DATE], revealed it was the policy of the facility to utilize a person-centered approach when determining the use of side rails. According to the policy, alternative approaches were attempted prior to installing a side or bed rail. If used, the facility would ensure correct installation, use, and maintenance of the rails. Further review of the policy revealed if after an attempted alternative to side/bed rails had been made, and the alternatives did not meet the resident's needs, the facility shall: [NAME] Evaluate the alternatives and document how these alternatives failed to meet the resident's assessed needs. If there was no appropriate alternative, document the reason. B. Assess the resident for risk of entrapment, and other risks associated with the use of side/bed rails. Review of the User/Service Manual for Devices and Side Rails, dated 2003, revealed when assessing the risk for entrapment, the facility needed to consider the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risk. Failure to do so could result in serious injury or death. 1. Review of the medical record revealed the facility admitted Resident #1 on [DATE], with [DIAGNOSES REDACTED]. Further review of the medical record revealed Resident #1 was admitted to Hospice care on [DATE]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), indicating the resident was moderately cognitively impaired. Further review of the MDS revealed Resident #1 was totally dependent upon two (2) staff members and a mechanical lift for transfers from bed, required extensive assistance of two (2) staff members for bed mobility, did not walk, had clear speech and a clear comprehension of others, and did not utilize bed rails as a restraint. Review of a Fall Risk assessment dated [DATE] revealed Resident #1 was unable to independently come to a standing position and required hands-on assistance to move from place to place. In addition, review of a Mobility Risk assessment dated [DATE], revealed Resident #1 required maximum assistance to roll from side to side and to maintain a sitting balance. Review of the Side (Bed) Rail Use assessment dated [DATE] for Resident #1 revealed the facility documented that Resident #1 expressed a desire to have the side rails raised while he/she was in bed. However, the facility failed to document Resident #1's reason why he/she wanted the side rails raised as required by the assessment. According to the assessment, two (2) one-fourth type side rails would most benefit Resident #1 to assist with turning and repositioning, bed mobility, and to have access to the call light. Further review of the assessment revealed the form required staff to document what other less restrictive alternative measures had been attempted for the resident and how Resident #1 responded to the less restrictive alternative measures. However, no alternative measures were documented. Further review of the Side Rail Use Assessment revealed the facility assessed Resident #1 to use medications that would require increased safety precautions. Further review of Resident #1's medical record revealed no documented evidence that the facility discussed the risks/benefits of side rail usage with the resident/resident's responsible party or obtained consent to utilize bed rails for the resident. Review of the physician's orders [REDACTED].#1 to increase the resident's mobility. However, review of Resident #1's Comprehensive Care Plan dated [DATE] revealed the facility developed a care plan for the resident with an intervention for one-half bed rails. The care plan stated staff were required to observe for injury or entrapment related to side rail use, and reposition as needed to avoid injury. Review of Resident #1's State Registered Nurse Aide (SRNA) care plan dated [DATE] revealed the SRNA care plan did not address the use of side rails. Interview with SRNA #5 on [DATE] at 3:43 PM, SRNA #2 on [DATE] at 5:22 PM, SRNA #4 on [DATE] at 6:30 PM, SRNA #3 on [DATE] at 9:18 AM, and with Registered Nurse #2 on [DATE] at 5:58 PM revealed Resident #1 tended to scoot down in his/her bed and/or lean to the right side of the bed/bed rail and required assistance to reposition because the resident was unable to move his/her legs. According to SRNAs #2, #3, and #4, the resident utilized one-half side rails. SRNA #2 stated the resident usually rang his/her call light when he/she needed to be pulled up in bed. RN #2 stated the resident often got into a fetal position in bed, close to the side rail, and required repositioning back to the middle of the bed. However, there was no documented evidence that the facility identified and assessed the risk factor related to the resident leaning/scooting to the right side of the bed/bed rail and/or implemented interventions to address the risk factor. On [DATE] at 4:05 PM an observation of the bed utilized by Resident #1 (according to the Administrator, Director of Nursing, and Maintenance Director) revealed one-half side rails on the bed and a foam mattress. Review of a facility investigation revealed on [DATE] (time was not documented), State Registered Nurse Aide (SRNA) #3 found Resident #1 on the floor, unresponsive. SRNA #3 yelled for a nurse and staff determined the resident was deceased . Review of the facility's Final Self Report Form revealed on [DATE] at 3:10 AM, SRNA #3, while making her nightly rounds, found Resident #1 unresponsive in his/her room. Resident #1 had his/her knees on the floor. The left side of the resident's head was lying on the mattress, facing the head of the bed, with his/her jaw lying on the side rail. The facility further documented that the SRNA had last checked on the resident on [DATE] between 1:00 AM and 1:30 AM, at which time Resident #1 was resting quietly in his/her bed, the side rails were up, and the call light was within reach. According to the investigation, the facility was unable to determine whether the resident attempted to get up unassisted without calling for help, experienced a fall, or rolled from the bed due to a medical emergency. The investigation stated that there were no signs of entrapment according to employee interviews and observation of three (3) reenactments of the incident. Review of a Nurse's Note dated [DATE] at 3:15 AM, revealed RN #1 documented that the resident was found on the floor on his/her knees on the right side of the bed with his/her neck against the rail and unresponsive. Further review revealed the resident was lowered to the floor where he/she was vigorously stimulated but remained unresponsive with no pulse or respirations. The Note stated the resident was under Hospice services and did not wish to be resuscitated; thus, no Cardiopulmonary Resuscitation (CPR) was performed. Further review of the Note revealed the resident was noted to have bruising and redness below left ear to mid-anterior neck with superficial skin tear left jaw one centimeter, superficial abrasion at mid-base of anterior neck. Large bruise right forearm four cm by three cm, abrasions to top of both knees 2.0 cm by 2.0 cm. No bleeding from skin tear or abrasions. Continued review of the Nurse's Note revealed the resident's family was notified and the resident's body was released to the funeral home. Interview with SRNA #3 on [DATE] at 9:18 AM revealed the last time she saw Resident #1 alive was at 12:00 AM on [DATE]. She stated the resident had drifted to the right side of the bed. She stated she repositioned the resident and did not observe the resident again until approximately 2:45 AM, when she found (Resident #1) hanging from the side rail, with (his/her) knees not quite touching the floor and (his/her) head was, like, caught on the side rail, under (his/her) chin. SRNA #3 further stated, I ran out into the hallway and (RN #1) came to help. The SRNA stated that after checking Resident #1 real quick, RN #1 stated either We need to get (the resident) off the side rail or Get (the resident) unstuck from the side rail. SRNA #3 stated by that time RN #2 had entered the room and the three (3) staff members lifted the resident off the side rail and laid the resident on the floor. SRNA #3 further stated, There were no red marks on (Resident #1's) knees, because (his/her) knees were not on the floor. However, SRNA #3 stated the resident had cuts and red indentions on (his/her) neck. Interview with RN #1 on [DATE] at 5:27 PM revealed at approximately 3:15 AM on [DATE], SRNA #3 was in the hallway yelling for RN #1 to come to Resident #1's room. RN #1 stated when she saw the resident, the lower half of the resident's body was off the right side of the bed, and the upper body was on the bed. She stated the resident's left side of chin was, like, against the side rail. The resident was not moving and (his/her) arms were down by (his/her) side. RN #1 stated she and SRNA #3 lowered Resident #1 to the floor, and attempted to stimulate the resident. RN #1 stated it was obvious the resident was dead. According to RN #1, there were red marks and indentions to the resident's neck where he/she was leaned up against the side rail. She stated that the red mark started on the left side of the neck below the ear, and continued to the middle of the resident's neck. In addition she stated there was an open area to the left side of the resident's jaw. RN #1 stated the resident could barely move his/her legs and did not believe the resident attempted to get out of bed/climb over the side rails. RN #1 stated she reported the incident to the facility Administrator, the resident's physician, and the resident's family. RN #1 stated she also called the funeral home to pick up Resident #1, but did not tell them about the incident, just that the resident passed away. Interview with RN #2 on [DATE] at 5:58 PM revealed at approximately 3:15 AM on [DATE], SRNA #3 was in the hallway yelling for help. According to RN #2, staff had already placed the resident on the floor on the right side of the bed when she entered the room, and RN #1 told her that the resident's head was in the side rail. She stated that RN #1 was trying to stimulate the resident, and she got on the floor to assist; however, Resident #1 was very pale, had no pulse, was not breathing, and had already expired. RN #2 also stated the resident had redness and indentations from the right side of the resident's neck that continued around to the left side of the neck. She stated there was also a small abrasion under the resident's jaw on the left side and dark areas to his/her knees. The RN further stated that she had found Resident #1 many times too far over to the right side of the bed, close to the side rails, and had to reposition the resident. Interview with Power of Attorney (POA) #2 on [DATE] at 4:15 PM, revealed the facility called on [DATE] at 3:30 AM to notify her that Resident #1 had passed away. She stated she did not remember the staff person's name that called, but the staff person told her Resident #1 had a medical episode, slid out of bed, and his/her neck was hung in the bed. POA #2 stated, They never told me the pros and cons of using side rails for (Resident #1), and the facility never told me if they had tried alternative methods before using the side rails. Interview with the Director of Nursing (DON) on [DATE] at 6:43 PM revealed the facility did not utilize one-fourth side rails for any residents. She stated all residents who required the use of side rails received one-half side rails. Continued interview with the Director of Nursing on [DATE] at 6:50 PM revealed the facility did not attempt any alternatives for Resident #1 as required by the facility's policy prior to initiating the side rails. Interview with the Administrator on [DATE] at 9:08 PM revealed the facility only utilized alternatives to side rails if the Side Rail Assessment revealed the resident could not use side rails. The Administrator further revealed that when a resident was admitted the resident/responsible party signed and consented to a restraint, and the facility utilized that form as the consent for side rails, even though it did not address the risks/benefits of side rail usage for the resident. Interview on [DATE] at 11:52 AM with the Funeral Home Director/Embalmer revealed staff did not notify him that the resident had rolled out of bed or anything about side rails. He stated he assumed that the resident died in bed because the resident was in bed when he arrived at the facility. The Funeral Home Director stated he would not have paid any attention to red marks or indentions around the neck because a lot of patients had red areas from oxygen tubes, etc. Interview with Physician #1 on [DATE] at 8:00 AM revealed when he signed the order for one-fourth length side rails to the resident's bed, he assumed that one-fourth length side rails were being used. Physician #1 stated the facility had not reported to him that the resident had one-half side rails to his/her bed and stated, I think that definitely contributed to (Resident #1's) death. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was seven (7), indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #2 required the assistance of one (1) staff member for bed mobility and transfers. Review of the physician's orders [REDACTED].#2 to increase the resident's mobility. According to a Side Rail Use Assessment for Resident #2 dated [DATE], the resident would benefit using two (2) one-fourth side rails. However, observation of Resident #2 on [DATE] at 8:20 PM revealed the resident was in the bed with a one-half side rail on each side of the resident's bed. 3. Review of the medical record revealed the facility admitted Resident #3 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was seven (7), indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #3 required the assistance of two (2) staff members for bed mobility and transfers. Review of a physician's orders [REDACTED].#3 to increase the resident's mobility. According to a Side Rail Use assessment dated [DATE], the resident would benefit using two (2) one-fourth side rails. However, observation of Resident #3 on [DATE] at 7:50 PM revealed the resident was in bed with two (2) one-half length side rails raised. Resident #3 stated he/she had side rails since admission to the facility and no one had ever discussed the risks or benefits of using side rails with him/her. 4. Continued review of the facility's policy titled Proper Use of Side Rails, revised [DATE], revealed the facility would inspect and regularly check mattresses and bed rails for gaps and areas of possible entrapment. In addition, the facility would ensure the bed rails had not shifted or loosened over time and the facility would follow the manufacturer's recommendations. Review of the facility's policy titled Bed Maintenance and Inspections, with a reviewed/revised date of [DATE], revealed the bed frame, mattress, and bed rail inspections would be conducted upon each item entering the facility and then placed on a regularly scheduled inspection and maintenance cycle according to the manufacturer's recommendations, to include the manufacturer's timeframe recommendations. Review of the User/Service Manual for the facility's beds dated 2007, under Maintenance and Inspection Information, revealed the facility should visually inspect the beds and accessories for broken welds or cracks, and check for loose hardware on a monthly basis, and any loose hardware should be tightened. Interview with the bed manufacturer Product Support Representative on [DATE] at 11:30 AM revealed the bed, mattress, and side rails were considered one (1) unit and should be inspected monthly by the facility. Review of the facility's Preventative Maintenance Log check list dated [DATE], revealed the facility documented that Resident #1's bed frame, crank, and side rails were rust free and in good working order. The bed wheels/casters locks were also documented to be in good repair and functioning properly. Further review of the Preventative Maintenance log revealed Resident #1's bed frame and side rails were inspected every four (4) months, not monthly as recommended in the User/Service Manual for the facility's beds, under Maintenance and Inspection Information. Interview with the Maintenance Director on [DATE] at 3:30 PM revealed he inspected 25 percent of the facility's beds and side rails every month; thus, each resident's bed/bed rail was checked every four months. Interview with the Administrator on [DATE] at 9:08 PM revealed the Maintenance Director was responsible for checking beds monthly. ****The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1. On [DATE], the facility reviewed and revised the Side Rail Policy and Side Rail Assessment. The policy stated side rails would be used only as an enabler to improve resident function. The policy defined enabler as a voluntary device, which facilitates movement and promotes independence, comfort, and safety. A decision guide would be used to determine if the side rail functioned as an enabler. If it was determined that a side rail would not function as an enabler for a resident, alternatives to side rails would be evaluated. If it was determined the alternative did not meet the resident's need, the facility would take the following steps: [NAME] Document how the alternatives failed to meet the resident's needs. If there was no appropriate alternative, document the reason. B. Assess the resident for risk of entrapment, and other risks associated with the use of side rails. The following are examples of potential risks: i. Accident hazards (i.e., falls, entrapment, injuries sustained from attempts to climb over, around, between, or through the rails) ii. Barrier from safely getting out of bed iii. Physical restraint (i.e., hinders from independently getting out of bed or performing routine activities) iv. Decline in function, such as muscle functioning/balance v. Skin integrity issues vi. Decline in other areas of daily living, such as using the bathroom, continence, eating, hydration, walking, and mobility vii. Negative psychosocial outcomes, such as altered self-esteem, feelings of isolation, or agitation/anxiety C. Obtain informed consent from the resident or the resident's representative for the use of bed rails, prior to installation/use. D. Determine whether the side rail is a restraint. Side rails will be considered a physical restraint when they limit the resident's freedom of movement. In such cases, the facility shall follow procedures related to physical restraints. E. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side rail. F. Obtain physician orders [REDACTED]. G. Reassessments will be conducted in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, any physical decline, or a change in the type of bed/mattress/rail. H. At the time a resident is determined to meet the criteria for side rails, the device decision guide will be utilized to ensure the rail is an enabler. I. If at any time side rails are removed from a resident's bed the resident's family and physician will be notified. 2. On [DATE], the Director of Nursing (DON) from a sister facility trained the facility's Administrator, DON, Medical Records Coordinator, Unit Coordinator (UC), and Activity Director/Licensed Practical Nurse (LPN) on the use of the facility's new Side Rail Policy and Side Rail Assessment form. 3. On [DATE], the DON, Medical Records Coordinator, and Activity Director/Licensed Practical Nurse (LPN), completed side rail assessments on all residents. The facility removed twenty (20) side rails from residents' beds. Two (2) were removed due to non-use and eighteen (18) were removed after the facility determined the risks of using the side rails outweighed the benefit of the side rail. Ten (10) residents in the facility are utilizing side rails. The DON assessed all ten (10) residents utilizing side rails for safety and appropriate consent. The DON will continue to monitor each of the ten (10) residents' safety while in bed daily for a week, then weekly times four (4) weeks, then monthly for two (2) months, and quarterly thereafter through the facility's Quality Assurance Program. In addition, the DON will monitor the twenty (20) residents who had their side rails removed daily for seven (7) days, and weekly thereafter for a month, and quarterly thereafter to ensure each resident's safety after the removal of the side rails. 4. Beginning on [DATE], the Social Worker contacted all resident families to discuss each resident's current situation related to side rails. The facility obtained consents from each resident or resident representative for each resident who will be utilizing side rails. 5. On [DATE], the sister facility's Administrator met with the Maintenance Director and reviewed the manufacturer's recommendations for all side rails in use in the facility. 6. On [DATE], the Maintenance Director checked all residents' beds to ensure they were in proper working order. In addition, the Maintenance Director inspected all beds equipped with side rails to ensure the side rails were not loose and that they were installed and being maintained per the manufacturer's recommendations. 7. Beginning on [DATE], the DON and Infection Control Nurse conducted daily rounds to ensure residents utilizing side rails were positioned appropriately in the bed and away from the side rails. The monitoring will continue daily for a week, then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. If any concerns were identified the Administrator would be notified immediately. 8. On [DATE] and [DATE], the DON and the UC trained all staff nurses on the revised Side Rail Policy and Side Rail Assessment Form. 9. On [DATE] and [DATE], the Maintenance Director trained the DON, UC, Infection Control Nurse, Administrator, Activity Director, and Medical Records Coordinator on how to appropriately install and remove side rails and how to check the side rails to ensure they were not loose and were properly installed. 10. Beginning on [DATE], the facility will screen all new admissions utilizing the facility's Side Rail Policy and Side Rail Assessment. Any residents admitted to the facility after normal business hours will have the assessment completed by the staff nurse assigned to the resident. The Therapy Department will then evaluate the resident for side rail usage. If Therapy deemed the resident appropriate for side rails, the staff will utilize the decision guide to ensure the side rails will act as an enabler for the resident. If a member of the nursing staff applies side rails to a new resident's bed upon admission, consent will first be obtained from the resident/resident's representative. The Maintenance Director will follow up the next business day to ensure the side rails were installed properly and presents no risk of injury to the resident. 11. On [DATE], the sister facility's Minimum Data Set (MDS) Coordinator trained the DON on developing an appropriate care plan for residents who utilize side rails and how to monitor the use of the side rail to ensure resident safety. 12. From [DATE] through [DATE], the MDS Nurse reviewed all resident care plans to ensure they reflected the resident's appropriate side rail status. The care plans were updated to include the appropriate use of side rails and specific monitoring of side rail use. 13. Beginning on [DATE], the Medical Records Coordinator and the MDS Assistant will review the side rail care plans for all residents utilizing side rails daily for seven (7) days to ensure no changes are needed and that the resident still meets criteria per the side rail policy. Reviews will continue daily for a week and then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. Any identified concerns will be reported to the Administrator immediately. 14. On [DATE], the DON trained facility nurses on updating and developing care plans for residents who utilize side rails. The care plan will include the resident's risks associated with the use of side rails and when care plans need to be updated related to side rails. 15. On [DATE], the sister facility's DON trained the DON and Medical Records Coordinator on obtaining appropriate physician orders [REDACTED]. Physician orders [REDACTED]. 16. On [DATE], the Medical Records Coordinator reviewed all physician's orders [REDACTED]. No concerns were identified. 17. On [DATE] and [DATE], the DON trained all nurses on obtaining appropriate physician orders [REDACTED]. 18. On [DATE], the sister facility's Administrator trained the Medical Records Coordinator and DON on accurate charting and ensuring observations and assessments were accurately documented at the time they were made. 19. On [DATE] and [DATE], the DON trained all Certified Nursing Assistants (CNAs) and licensed nurses on the accuracy of documentation, and making sure the documentation reflected the accurate time an event occurred. 20. On [DATE], the Medical Records Coordinator reviewed all medical records to ensure any new orders or resident events occurring in the last month were documented appropriately and were accurate. 21. Beginning on [DATE], the DON will review the twenty-four-hour report form daily and then compare that documentation to the resident's medical record to ensure all events were documented accurately and timely. Any identified concerns will be reported to the Administrator immediately. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed on [DATE], as alleged by the facility: 1. Review of the facility's Side Rail Policy and Side Rail Assessment Form revealed it was revised as of [DATE]. Interview with the sister facility's DON on [DATE] at 10:25 AM, revealed the policy and assessment were revised to include all required components for ensuring residents were assessed appropriately for side rail use and that any use of side rails in the facility would be monitored for safety and appropriate functioning. 2. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, the UC at 12:27 PM, and the Activity Director at 3:22 PM, revealed a sister facility's Director of Nursing (DON) trained the staff on how to use the facility's revised Side Rail Policy and Side Rail Assessment Form. 3. Review of Side Rail Assessment Form screenings dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, and the Activity Director at 3:23 PM, revealed all residents were screened for the use of side rails. In addition, review of the Side Rail Audits dated [DATE] thru [DATE], revealed the DON had monitored the residents who had their side rails removed daily. Interview with the DON on [DATE] at 11:45 AM, revealed she had been monitoring the residents who had their side rails removed. Review of the medical records of the ten (10) residents who had their side rails removed revealed the residents' families and physicians were notified. Interview with Family Member #3 on [DATE] at 9:50 AM, revealed he/she was notified that his/her spouse's side rails were removed from the bed. Further interview revealed the facility explained the risk of side rails, and supplied the resident with a wing mattress. 4. Review of Safety

Based on observation, interview, record review, and review of facility policies and User/Service Manual for Devices and Side Rails, it was determined the facility failed to develop a comprehensive, person-centered care plan for three (3) of three (3) sampled residents (Residents #1, #2, and #3). Resident #1 had a physician's orders [REDACTED]. However, the facility developed a care plan for Resident #1 with an intervention to utilize one-half bed/side rails (longer rails). Interviews with staff revealed the resident utilized one-half side/bed rails, and any resident who required a side/bed rail utilized a one-half rail. On [DATE], State Registered Nurse Aide (SRNA) #3 found Resident #1 at approximately 3:00 AM, with his/her head caught in the side/bed rail and without any signs of life. In addition, the facility failed to ensure a care plan was developed for Residents #2 and #3 for one-fourth side rails as ordered by their physician with interventions to address the residents' safe use of the rails. Residents #2 and #3 were observed utilizing one-half side rails. The facility's failure to ensure care plans were developed in accordance with physician orders [REDACTED]. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835) and (F842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835) and (F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Care Plan, Interdisciplinary, reviewed [DATE], revealed an updated and current individualized care plan was necessary to ensure each resident received the nursing care needed to treat identified problems that were specific to each resident. The policy stated that the care plan process would use the usual format: assess, plan, implement, evaluate, and reassess. The policy further stated that the Interdisciplinary Team would state the resident's identified problems, conditions, limitations, maintenance levels, and improvement possibilities in functional or behavioral terms (how it will be a problem for the resident, how it will limit or jeopardize the resident's ability to complete tasks of daily life or in any way affect the resident's well-being). Review of the User/Service Manual for Devices and Side Rails, dated 2003, revealed when assessing the risk for entrapment, the facility needed to review the resident's physical and mental condition and initiate an appropriate individual care plan to address entrapment risks. Failure to do so could result in serious injury or death. 1. Review of the medical record for Resident #1 revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), indicating the resident was moderately cognitively impaired. According to the assessment, the resident did not utilize bed rails as a restraint for the resident. Review of the Side Rail Use assessment dated [DATE], revealed two (2) one-fourth length side rails would benefit Resident #1. In addition, the resident had a physician's orders [REDACTED]. However, review of Resident #1's Comprehensive Care Plan dated [DATE], revealed the facility developed a care plan with an intervention for one-half side rails. Interviews with SRNA #2 on [DATE] at 5:22 PM, SRNA #4 on [DATE] at 6:30 PM, SRNA #3 on [DATE] at 9:18 AM, revealed Resident #1 utilized one-half side rails when he/she was a resident of the facility. Continued interview with SRNA #3 on [DATE] at 9:18 AM revealed on [DATE] at approximately 2:45 AM, she found (Resident #1) hanging from the side rail, with (his/her) knees not quite touching the floor and (his/her) head was, like, caught on the side rail, under (his/her) chin. SRNA #3 further stated that the resident had cuts and red indentions on (his/her) neck from the side rail. Review of a Nurse's Note dated [DATE] at 3:15 AM, revealed RN #1 documented that the resident was found on the floor on his/her knees on the right side of the bed with his/her neck against the rail and was unresponsive. Resident #1 was lowered to the floor where he/she was vigorously stimulated but remained unresponsive with no pulse or respirations. The Note stated the resident was under Hospice Services and did not wish to be resuscitated; thus, no Cardiopulmonary Resuscitation (CPR) was performed. Further review of the Note revealed the resident was noted to have bruising and redness below left ear to mid-anterior neck with superficial skin tear left jaw one centimeter, superficial abrasion at mid-base of anterior neck. Large bruise right forearm four cm (centimeter) by three cm, abrasions to top of both knees 2.0 cm by 2.0 cm. No bleeding from skin tear or abrasions. Continued review of the Nurse's Note revealed the resident's family was notified and the resident's body was released to the funeral home. 2. Review of Resident #2's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was seven (7), indicating the resident was severely cognitively impaired. Further review of the MDS revealed Resident #2 required the assistance of one (1) staff member for bed mobility and transfers. Review of the physician's orders [REDACTED].#2, to increase the resident's mobility. According to a Side Rail Use Assessment for Resident #2 dated [DATE], the resident would benefit using two (2) one-fourth side rails. However, observation of Resident #2 on [DATE] at 8:20 PM revealed the resident was in the bed with a one-half side rail on each side of the resident's bed. Review of Resident #2's Comprehensive Care Plan initially dated [DATE], revealed the facility failed to develop a care plan related to the use of side rails with interventions to ensure the resident's safety. 3. Review of the medical record revealed the facility admitted Resident #3 on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was seven (7), indicating the resident was severely cognitively impaired. Further review of the MDS revealed the facility assessed Resident #3 to require the assistance of two (2) staff members for bed mobility and transfers. Review of Resident #3's Comprehensive Care Plan dated [DATE], revealed the facility developed a care plan with an intervention for the resident to utilize one (1) to two (2) side rails to aid in independence in bed mobility. The care plan did not address the size/type of rail, nor did the facility develop interventions to ensure the resident's safety with side rails. Review of a physician's orders [REDACTED].#3 to increase the resident's mobility. According to a Side Rail Use assessment dated [DATE], the resident would benefit using two (2) one-fourth side rails. However, observation of Resident #3 on [DATE] at 7:50 PM revealed the resident was in bed with two (2) one-half length side rails raised. During interview with Resident #3, he/ she stated he/she had side rails since admission to the facility and no one had ever discussed the risks or benefits of using side rails. Interview with the Director of Nursing (DON) on [DATE] at 6:43 PM revealed the facility did not utilize one-fourth side rails for any resident. She stated all residents who required the use of side rails received one-half side rails. Interview with the Administrator on [DATE] at 11:25 AM revealed the MDS Coordinator was responsible to ensure the care plans were correct and updated accordingly. Interview with the MDS Coordinator on [DATE] at 4:55 PM revealed she initiated residents' comprehensive care plans and the MDS Assistant reviewed care plans quarterly. According to the MDS Coordinator, she or the MDS Assistant should have identified that the residents' care plans did not match the physician's orders [REDACTED]. ****The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1. On [DATE], the facility reviewed and revised the Side Rail Policy and Side Rail Assessment. The policy stated side rails would be used only as an enabler to improve resident function. The policy defined enabler as a voluntary device, which facilitates movement and promotes independence, comfort, and safety. A decision guide would be used to determine if the side rail functioned as an enabler. If it was determined that a side rail would not function as an enabler for a resident, alternatives to side rails would be evaluated. If it was determined the alternative did not meet the resident's need, the facility would take the following steps: [NAME] Document how the alternatives failed to meet the resident's needs. If there was no appropriate alternative, document the reason. B. Assess the resident for risk of entrapment, and other risks associated with the use of side rails. The following are examples of potential risks: i. Accident hazards (i.e., falls, entrapment, injuries sustained from attempts to climb over, around, between, or through the rails) ii. Barrier from safely getting out of bed iii. Physical restraint (i.e., hinders from independently getting out of bed or performing routine activities) iv. Decline in function, such as muscle functioning/balance v. Skin integrity issues vi. Decline in other areas of daily living, such as using the bathroom, continence, eating, hydration, walking, and mobility vii. Negative psychosocial outcomes, such as altered self-esteem, feelings of isolation, or agitation/anxiety C. Obtain informed consent from the resident or the resident's representative for the use of bed rails, prior to installation/use. D. Determine whether the side rail is a restraint. Side rails will be considered a physical restraint when they limit the resident's freedom of movement. In such cases, the facility shall follow procedures related to physical restraints. E. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side rail. F. Obtain physician orders [REDACTED]. G. Reassessments will be conducted in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, any physical decline, or a change in the type of bed/mattress/rail. H. At the time a resident is determined to meet the criteria for side rails, the device decision guide will be utilized to ensure the rail is an enabler. I. If at any time side rails are removed from a resident's bed the resident's family and physician will be notified. 2. On [DATE], the Director of Nursing (DON) from a sister facility trained the facility's Administrator, DON, Medical Records Coordinator, Unit Coordinator (UC), and Activity Director/Licensed Practical Nurse (LPN) on the use of the facility's new Side Rail Policy and Side Rail Assessment form. 3. On [DATE], the DON, Medical Records Coordinator, and Activity Director/Licensed Practical Nurse (LPN), completed side rail assessments on all residents. The facility removed twenty (20) side rails from residents' beds. Two (2) were removed due to non-use and eighteen (18) were removed after the facility determined the risks of using the side rails outweighed the benefit of the side rail. Ten (10) residents in the facility are utilizing side rails. The DON assessed all ten (10) residents utilizing side rails for safety and appropriate consent. The DON will continue to monitor each of the ten (10) residents' safety while in bed daily for a week, then weekly times four (4) weeks, then monthly for two (2) months, and quarterly thereafter through the facility's Quality Assurance Program. In addition, the DON will monitor the twenty (20) residents who had their side rails removed daily for seven (7) days, and weekly thereafter for a month, and quarterly thereafter to ensure each resident's safety after the removal of the side rails. 4. Beginning on [DATE], the Social Worker contacted all resident families to discuss each resident's current situation related to side rails. The facility obtained consents from each resident or resident representative for each resident who will be utilizing side rails. 5. On [DATE], the sister facility's Administrator met with the Maintenance Director and reviewed the manufacturer's recommendations for all side rails in use in the facility. 6. On [DATE], the Maintenance Director checked all residents' beds to ensure they were in proper working order. In addition, the Maintenance Director inspected all beds equipped with side rails to ensure the side rails were not loose and that they were installed and being maintained per the manufacturer's recommendations. 7. Beginning on [DATE], the DON and Infection Control Nurse conducted daily rounds to ensure residents utilizing side rails were positioned appropriately in the bed and away from the side rails. The monitoring will continue daily for a week, then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. If any concerns were identified the Administrator would be notified immediately. 8. On [DATE] and [DATE], the DON and the UC trained all staff nurses on the revised Side Rail Policy and Side Rail Assessment Form. 9. On [DATE] and [DATE], the Maintenance Director trained the DON, UC, Infection Control Nurse, Administrator, Activity Director, and Medical Records Coordinator on how to appropriately install and remove side rails and how to check the side rails to ensure they were not loose and were properly installed. 10. Beginning on [DATE], the facility will screen all new admissions utilizing the facility's Side Rail Policy and Side Rail Assessment. Any residents admitted to the facility after normal business hours will have the assessment completed by the staff nurse assigned to the resident. The Therapy Department will then evaluate the resident for side rail usage. If Therapy deemed the resident appropriate for side rails, the staff will utilize the decision guide to ensure the side rails will act as an enabler for the resident. If a member of the nursing staff applies side rails to a new resident's bed upon admission, consent will first be obtained from the resident/resident's representative. The Maintenance Director will follow up the next business day to ensure the side rails were installed properly and presents no risk of injury to the resident. 11. On [DATE], the sister facility's Minimum Data Set (MDS) Coordinator trained the DON on developing an appropriate care plan for residents who utilize side rails and how to monitor the use of the side rail to ensure resident safety. 12. From [DATE] through [DATE], the MDS Nurse reviewed all resident care plans to ensure they reflected the resident's appropriate side rail status. The care plans were updated to include the appropriate use of side rails and specific monitoring of side rail use. 13. Beginning on [DATE], the Medical Records Coordinator and the MDS Assistant will review the side rail care plans for all residents utilizing side rails daily for seven (7) days to ensure no changes are needed and that the resident still meets criteria per the side rail policy. Reviews will continue daily for a week and then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. Any identified concerns will be reported to the Administrator immediately. 14. On [DATE], the DON trained facility nurses on updating and developing care plans for residents who utilize side rails. The care plan will include the resident's risks associated with the use of side rails and when care plans need to be updated related to side rails. 15. On [DATE], the sister facility's DON trained the DON and Medical Records Coordinator on obtaining appropriate physician orders [REDACTED]. Physician orders [REDACTED]. 16. On [DATE], the Medical Records Coordinator reviewed all physician's orders [REDACTED]. No concerns were identified. 17. On [DATE] and [DATE], the DON trained all nurses on obtaining appropriate physician orders [REDACTED]. 18. On [DATE], the sister facility's Administrator trained the Medical Records Coordinator and DON on accurate charting and ensuring observations and assessments were accurately documented at the time they were made. 19. On [DATE] and [DATE], the DON trained all Certified Nursing Assistants (CNAs) and licensed nurses on the accuracy of documentation, and making sure the documentation reflected the accurate time an event occurred. 20. On [DATE], the Medical Records Coordinator reviewed all medical records to ensure any new orders or resident events occurring in the last month were documented appropriately and were accurate. 21. Beginning on [DATE], the DON will review the twenty-four-hour report form daily and then compare that documentation to the resident's medical record to ensure all events were documented accurately and timely. Any identified concerns will be reported to the Administrator immediately. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed on [DATE], as alleged by the facility: 1. Review of the facility's Side Rail Policy and Side Rail Assessment Form revealed it was revised as of [DATE]. Interview with the sister facility's DON on [DATE] at 10:25 AM, revealed the policy and assessment were revised to include all required components for ensuring residents were assessed appropriately for side rail use and that any use of side rails in the facility would be monitored for safety and appropriate functioning. 2. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, the UC at 12:27 PM, and the Activity Director at 3:22 PM, revealed a sister facility's Director of Nursing (DON) trained the staff on how to use the facility's revised Side Rail Policy and Side Rail Assessment Form. 3. Review of Side Rail Assessment Form screenings dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, and the Activity Director at 3:23 PM, revealed all residents were screened for the use of side rails. In addition, review of the Side Rail Audits dated [DATE] thru [DATE], revealed the DON had monitored the residents who had their side rails removed daily. Interview with the DON on [DATE] at 11:45 AM, revealed she had been monitoring the residents who had their side rails removed. Review of the medical records of the ten (10) residents who had their side rails removed revealed the residents' families and physicians were notified. Interview with Family Member #3 on [DATE] at 9:50 AM, revealed he/she was notified that his/her spouse's side rails were removed from the bed. Further interview revealed the facility explained the risk of side rails, and supplied the resident with a wing mattress. 4. Review of Safety Consents dated [DATE] revealed beginning on [DATE], the Social Worker contacted residents' families to discuss the resident's current side rail usage. All residents deemed to need the side rails had consent form acknowledgements signed by the resident or the resident's Responsible Party. 5. Review of a sign-in sheet dated [DATE], and interview with the Maintenance Director on [DATE] at 2:35 PM, revealed the Maintenance Director was trained by the sister facility's Administrator on the manufacturer's recommendations for all side rails utilized in the facility. 6. Review of Bed Check Audits and interview with the Maintenance Director on [DATE] at 2:35 PM, revealed he conducted a check of all resident beds on [DATE] to ensure the beds were working properly. Beds equipped with side rails were also checked to ensure the side rails were not loose and were installed per manufacturer's recommendations. 7. Review of Bed Check Audits completed [DATE] thru [DATE], and interviews on [DATE], with the DON at 11:45 AM and the Infection Control Nurse at 2:55 PM, revealed the DON and the Infection Control Nurse monitored daily to ensure side rails were in place for those residents who utilize them, and that they were an enabler for the resident, and that the residents were positioned appropriately in the bed away from the rails. 8. Review of sign-in sheets dated [DATE] and [DATE], and interviews on [DATE] with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed nursing staff were trained on using the revised Side Rail Policy and Side Rail Assessment Form. 9. Review of sign-in sheets dated [DATE] and [DATE], and interviews on [DATE] with the DON at 11:45 AM, the UC at 12:27 PM, the Infection Control Nurse at 2:55 PM, the Administrator at 10:50 AM, the Activity Director at 3:23 PM, and the Medical Records Coordinator at 4:25 PM, revealed they were trained on how to check the side rails to ensure they were not loose and working properly. The staff also stated they were required to perform return demonstrations. 10. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM revealed all the staff were trained on the Decision Guide and screening new admissions for the appropriateness of side rails. Interview with the Maintenance Director on [DATE] at 2:35 PM revealed that if a staff member other than himself installed a side rail on a bed, he would follow up the next business day to ensure proper installation of the side rails. 11. Review of a sign-in sheet and interview with the DON on [DATE] at 11:45 AM revealed she was trained by the sister facility's MDS Coordinator on developing and implementing side rail care plans for residents utilizing side rails, with specific monitoring requirements for the side rails. 12. Review of a care plan checklist and interview with the MDS Coordinator on [DATE] at 3:43 PM, revealed from [DATE] through [DATE], all care plans were reviewed to ensure the appropriate side rail status was correct for the resident. 13. Review of care plans for Resident #3, Resident #4, and Resident #5 revealed they were updated to reflect the correct size of side rail being utilized and to ensure the resident's Side Rail Assessment had been completed. Interviews on [DATE], at 4:25 PM with the Medical Records Coordinator and at 3:43 PM with the MDS Coordinator, revealed all resident care plans were updated to include the correct side rail and the risks associated with side rail usage for the resident. 14. Review of sign-in sheets dated [DATE] and [DATE] revealed the DON trained all nurses on care plan updates and the use of side rails, the risks of side rails for residents, and when side rail updates need to be completed. Staff were also required to complete a post-test. Interviews on [DATE], with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed staff were trained on updating care plans related to the use of side rails. 15. Review of a sign-in sheet dated [DATE] and interviews on [DATE], with the sister facility's DON at 10:25 AM, the DON at 11:45 AM, and the Medical Records Coordinator at 4:25 PM, revealed the DON and Medical Records Coordinator were trained by the sister facility's DON on obtaining appropriate physician orders [REDACTED]. Review of an audit form revealed physician orders [REDACTED]. 17. Review of sign-in sheets dated [DATE] and [DATE] and interviews on [DATE], with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed the nurses were trained by the DON on physician's orders [REDACTED]. 18. Review of a sign-in sheet dated [DATE] and interviews on [DATE], with the Medical Records Coordinator at 4:25 PM and the DON at 11:45 AM, revealed they were trained by the sister facility's Administrator on accurate documentation and documenting the correct time an event occurred on the nurse's note. 19. Observation of sign-in sheets dated [DATE] and [DATE] and interviews on [DATE], with SRNA #6 at 2:47 PM, SRNA #7 at 1:42 PM, SRNA #8 at 12:52 PM, LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed the staff had been trained on accurate and timely documentation. 20. Review of a facility roster dated [DATE], and interview with the Medical Records Coordinator on [DATE] at 4:25 PM, revealed she had reviewed all nursing entries for the last month to ensure appropriate documentation had been made. 21. Review of medical record audits dated [DATE] thru [DATE] and interview with the DON on [DATE] at 11:45 AM revealed she had been auditing medical records daily to ensure staff were documenting timely and accurately.

Based on interview, record review, review of a facility investigation, and review of the Administrator's job description the facility failed to be administered in a manner that enabled it to attain or maintain the highest practicable physical well-being of each resident. On [DATE], at approximately 3:00 AM, staff found Resident #1 with his/her upper body hanging off the bed and his/her neck in the bed/side rail, deceased . Facility staff reported the resident's death to the Administrator and an investigation was initiated. According to the investigation, the cause of the resident's death could not be determined and there were no signs of entrapment in the resident's bed rails. However, the Administrator failed to identify that the resident was not utilizing the length of bed/side rails that the facility had assessed the resident to require and the physician had ordered for the resident; failed to address red marks, indentions, and abrasions to the resident's neck/jaw; and failed to identify/address that Resident #1 had not been observed/assessed for approximately three (3) hours (12:00 to 3:00 AM). The facility's failure to ensure it was administered in an effective manner has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the Administrator's job description, not dated, revealed the primary purpose of the Administrator's job was to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care could be provided to residents at all times. Review of a facility investigation revealed on [DATE] (time was not documented), State Registered Nurse Aide (SRNA) #3 found Resident #1 on the floor, unresponsive. According to the investigation, staff determined the resident was deceased . Review of the facility's Final Self Report Form revealed on [DATE] at 3:10 AM, SRNA #1 found Resident #1 with his/her knees on the floor, with the left side of the resident's head on the mattress, facing the head of the bed, with his/her jaw lying on the side rail. The facility further documented that the SRNA had last checked on the resident on [DATE] between 1:00 and 1:30 AM, at which time Resident #1 was resting quietly in his/her bed, the side rails were up, and the call light was within reach. According to the investigation, the facility was unable to determine whether the resident attempted to get up unassisted without calling for help, experienced a fall, or rolled from the bed due to a medical emergency. The investigation further revealed that based on interviews with staff and reenactments of the incident, the facility determined that there were no signs of entrapment in the resident's bed rails. According to a review of the facility's investigation, no concerns were identified related to Resident #1's death. However, a review of Resident #1's medical record revealed the facility did not utilize bed rails for the resident in accordance with physician's orders [REDACTED]. Resident #1 had a physician's orders [REDACTED]. Further, review of Resident #1's Side (Bed) Rail Use assessment dated [DATE], revealed the facility reassessed the resident's side rail usage and determined that two (2) one-fourth type side rails would most benefit Resident #1 to assist with turning and repositioning, bed mobility, and accessing the call light. However, review of Resident #1's Comprehensive Care Plan dated [DATE], revealed the facility developed a care plan for the resident with an intervention for one-half length bed rails. Interview with the Director of Nursing (DON) on [DATE] at 6:43 PM revealed the facility did not utilize one-fourth side rails for any residents. She stated all residents who required the use of side rails received one-half side rails. Continued review of the facility's investigation revealed no documented evidence that Resident #1 had any injuries or that the facility considered the injuries when determining the cause of the resident's death. However, interview with SRNA #3 on [DATE] at 9:18 AM, Registered Nurse (RN) #1 on [DATE] at 5:37 PM, and RN #2 on [DATE] at 5:58 PM revealed Resident #1 had indentions/bruising/cuts/abrasions to the resident's neck. In addition, even though the facility investigation stated there were no signs of entrapment, SNRA #3 stated she found (Resident #1) hanging from the side rail, with (his/her) knees not quite touching the floor, and (his/her) head was, like, caught on the side rail, under (his/her) chin. In addition, SRNA #3 stated the last time she saw Resident #1 alive was at 12:00 AM on [DATE], not 1:00 to 1:30 AM as stated in the facility's investigation. Continued review of the facility's investigation of Resident #1's death revealed no documented evidence that the facility identified that RN #1 had not assessed Resident #1 at 2:22 AM as documented in the medical record. Review of Resident #1's Nurse's Notes dated [DATE] at 2:22 AM, revealed RN #1 documented that the resident was resting well, eyes closed, respirations even and unlabored, denies pain, and vital signs stable. However, an interview with RN #1 on [DATE] at 5:37 PM revealed that even though she documented an assessment of Resident #1 on [DATE] at 2:22 AM, she only walked by the resident's room and could not physically see Resident #1. Interview with the Administrator on [DATE] at 9:08 PM and on [DATE] at 11:25 AM revealed she was out of town, on vacation, when RN #1 notified her of Resident #1's death. She stated she told RN #1 to have the staff involved write statements before their shift ended. She stated she attempted to notify the Corporate Compliance Officer (CCO) when the incident occurred; however, the CCO did not answer. Subsequently, an investigation was not initiated until later that day. The Administrator stated that based on her investigation, which included staff interviews and reenactments of the incident with RN #1 and the Maintenance staff person (not SRNA #3), the facility was unable to determine the cause of the resident's death, but she did not believe the death was a result of the side rail, even though the resident was not utilizing the appropriate length side rails. According to the Administrator, after the resident's death, the facility began reassessing residents' side rails and had discontinued side rails for approximately fifteen (15) residents because their cognition had declined; however, she had not identified/addressed that the incorrect length/size side rails was being utilized for residents. Further interview with the Administrator revealed she did not know why the red marks and indentions to the resident's neck/jaw had not been addressed in the facility's investigation. ****The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1. On [DATE], the facility reviewed and revised the Side Rail Policy and Side Rail Assessment. The policy stated side rails would be used only as an enabler to improve resident function. The policy defined enabler as a voluntary device, which facilitates movement and promotes independence, comfort, and safety. A decision guide would be used to determine if the side rail functioned as an enabler. If it was determined that a side rail would not function as an enabler for a resident, alternatives to side rails would be evaluated. If it was determined the alternative did not meet the resident's need, the facility would take the following steps: [NAME] Document how the alternatives failed to meet the resident's needs. If there was no appropriate alternative, document the reason. B. Assess the resident for risk of entrapment, and other risks associated with the use of side rails. The following are examples of potential risks: i. Accident hazards (i.e., falls, entrapment, injuries sustained from attempts to climb over, around, between, or through the rails) ii. Barrier from safely getting out of bed iii. Physical restraint (i.e., hinders from independently getting out of bed or performing routine activities) iv. Decline in function, such as muscle functioning/balance v. Skin integrity issues vi. Decline in other areas of daily living, such as using the bathroom, continence, eating, hydration, walking, and mobility vii. Negative psychosocial outcomes, such as altered self-esteem, feelings of isolation, or agitation/anxiety C. Obtain informed consent from the resident or the resident's representative for the use of bed rails, prior to installation/use. D. Determine whether the side rail is a restraint. Side rails will be considered a physical restraint when they limit the resident's freedom of movement. In such cases, the facility shall follow procedures related to physical restraints. E. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side rail. F. Obtain physician orders [REDACTED]. G. Reassessments will be conducted in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, any physical decline, or a change in the type of bed/mattress/rail. H. At the time a resident is determined to meet the criteria for side rails, the device decision guide will be utilized to ensure the rail is an enabler. I. If at any time side rails are removed from a resident's bed the resident's family and physician will be notified. 2. On [DATE], the Director of Nursing (DON) from a sister facility trained the facility's Administrator, DON, Medical Records Coordinator, Unit Coordinator (UC), and Activity Director/Licensed Practical Nurse (LPN) on the use of the facility's new Side Rail Policy and Side Rail Assessment form. 3. On [DATE], the DON, Medical Records Coordinator, and Activity Director/Licensed Practical Nurse (LPN), completed side rail assessments on all residents. The facility removed twenty (20) side rails from residents' beds. Two (2) were removed due to non-use and eighteen (18) were removed after the facility determined the risks of using the side rails outweighed the benefit of the side rail. Ten (10) residents in the facility are utilizing side rails. The DON assessed all ten (10) residents utilizing side rails for safety and appropriate consent. The DON will continue to monitor each of the ten (10) residents' safety while in bed daily for a week, then weekly times four (4) weeks, then monthly for two (2) months, and quarterly thereafter through the facility's Quality Assurance Program. In addition, the DON will monitor the twenty (20) residents who had their side rails removed daily for seven (7) days, and weekly thereafter for a month, and quarterly thereafter to ensure each resident's safety after the removal of the side rails. 4. Beginning on [DATE], the Social Worker contacted all resident families to discuss each resident's current situation related to side rails. The facility obtained consents from each resident or resident representative for each resident who will be utilizing side rails. 5. On [DATE], the sister facility's Administrator met with the Maintenance Director and reviewed the manufacturer's recommendations for all side rails in use in the facility. 6. On [DATE], the Maintenance Director checked all residents' beds to ensure they were in proper working order. In addition, the Maintenance Director inspected all beds equipped with side rails to ensure the side rails were not loose and that they were installed and being maintained per the manufacturer's recommendations. 7. Beginning on [DATE], the DON and Infection Control Nurse conducted daily rounds to ensure residents utilizing side rails were positioned appropriately in the bed and away from the side rails. The monitoring will continue daily for a week, then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. If any concerns were identified the Administrator would be notified immediately. 8. On [DATE] and [DATE], the DON and the UC trained all staff nurses on the revised Side Rail Policy and Side Rail Assessment Form. 9. On [DATE] and [DATE], the Maintenance Director trained the DON, UC, Infection Control Nurse, Administrator, Activity Director, and Medical Records Coordinator on how to appropriately install and remove side rails and how to check the side rails to ensure they were not loose and were properly installed. 10. Beginning on [DATE], the facility will screen all new admissions utilizing the facility's Side Rail Policy and Side Rail Assessment. Any residents admitted to the facility after normal business hours will have the assessment completed by the staff nurse assigned to the resident. The Therapy Department will then evaluate the resident for side rail usage. If Therapy deemed the resident appropriate for side rails, the staff will utilize the decision guide to ensure the side rails will act as an enabler for the resident. If a member of the nursing staff applies side rails to a new resident's bed upon admission, consent will first be obtained from the resident/resident's representative. The Maintenance Director will follow up the next business day to ensure the side rails were installed properly and presents no risk of injury to the resident. 11. On [DATE], the sister facility's Minimum Data Set (MDS) Coordinator trained the DON on developing an appropriate care plan for residents who utilize side rails and how to monitor the use of the side rail to ensure resident safety. 12. From [DATE] through [DATE], the MDS Nurse reviewed all resident care plans to ensure they reflected the resident's appropriate side rail status. The care plans were updated to include the appropriate use of side rails and specific monitoring of side rail use. 13. Beginning on [DATE], the Medical Records Coordinator and the MDS Assistant will review the side rail care plans for all residents utilizing side rails daily for seven (7) days to ensure no changes are needed and that the resident still meets criteria per the side rail policy. Reviews will continue daily for a week and then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. Any identified concerns will be reported to the Administrator immediately. 14. On [DATE], the DON trained facility nurses on updating and developing care plans for residents who utilize side rails. The care plan will include the resident's risks associated with the use of side rails and when care plans need to be updated related to side rails. 15. On [DATE], the sister facility's DON trained the DON and Medical Records Coordinator on obtaining appropriate physician orders [REDACTED]. Physician orders [REDACTED]. 16. On [DATE], the Medical Records Coordinator reviewed all physician's orders [REDACTED]. No concerns were identified. 17. On [DATE] and [DATE], the DON trained all nurses on obtaining appropriate physician orders [REDACTED]. 18. On [DATE], the sister facility's Administrator trained the Medical Records Coordinator and DON on accurate charting and ensuring observations and assessments were accurately documented at the time they were made. 19. On [DATE] and [DATE], the DON trained all Certified Nursing Assistants (CNAs) and licensed nurses on the accuracy of documentation, and making sure the documentation reflected the accurate time an event occurred. 20. On [DATE], the Medical Records Coordinator reviewed all medical records to ensure any new orders or resident events occurring in the last month were documented appropriately and were accurate. 21. Beginning on [DATE], the DON will review the twenty-four-hour report form daily and then compare that documentation to the resident's medical record to ensure all events were documented accurately and timely. Any identified concerns will be reported to the Administrator immediately. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed on [DATE], as alleged by the facility: 1. Review of the facility's Side Rail Policy and Side Rail Assessment Form revealed it was revised as of [DATE]. Interview with the sister facility's DON on [DATE] at 10:25 AM, revealed the policy and assessment were revised to include all required components for ensuring residents were assessed appropriately for side rail use and that any use of side rails in the facility would be monitored for safety and appropriate functioning. 2. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, the UC at 12:27 PM, and the Activity Director at 3:22 PM, revealed a sister facility's Director of Nursing (DON) trained the staff on how to use the facility's revised Side Rail Policy and Side Rail Assessment Form. 3. Review of Side Rail Assessment Form screenings dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, and the Activity Director at 3:23 PM, revealed all residents were screened for the use of side rails. In addition, review of the Side Rail Audits dated [DATE] thru [DATE], revealed the DON had monitored the residents who had their side rails removed daily. Interview with the DON on [DATE] at 11:45 AM, revealed she had been monitoring the residents who had their side rails removed. Review of the medical records of the ten (10) residents who had their side rails removed revealed the residents' families and physicians were notified. Interview with Family Member #3 on [DATE] at 9:50 AM, revealed he/she was notified that his/her spouse's side rails were removed from the bed. Further interview revealed the facility explained the risk of side rails, and supplied the resident with a wing mattress. 4. Review of Safety Consents dated [DATE] revealed beginning on [DATE], the Social Worker contacted residents' families to discuss the resident's current side rail usage. All residents deemed to need the side rails had consent form acknowledgements signed by the resident or the resident's Responsible Party. 5. Review of a sign-in sheet dated [DATE], and interview with the Maintenance Director on [DATE] at 2:35 PM, revealed the Maintenance Director was trained by the sister facility's Administrator on the manufacturer's recommendations for all side rails utilized in the facility. 6. Review of Bed Check Audits and interview with the Maintenance Director on [DATE] at 2:35 PM, revealed he conducted a check of all resident beds on [DATE] to ensure the beds were working properly. Beds equipped with side rails were also checked to ensure the side rails were not loose and were installed per manufacturer's recommendations. 7. Review of Bed Check Audits completed [DATE] thru [DATE], and interviews on [DATE], with the DON at 11:45 AM and the Infection Control Nurse at 2:55 PM, revealed the DON and the Infection Control Nurse monitored daily to ensure side rails were in place for those residents who utilize them, and that they were an enabler for the resident, and that the residents were positioned appropriately in the bed away from the rails. 8. Review of sign-in sheets dated [DATE] and [DATE], and interviews on [DATE] with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed nursing staff were trained on using the revised Side Rail Policy and Side Rail Assessment Form. 9. Review of sign-in sheets dated [DATE] and [DATE], and interviews on [DATE] with the DON at 11:45 AM, the UC at 12:27 PM, the Infection Control Nurse at 2:55 PM, the Administrator at 10:50 AM, the Activity Director at 3:23 PM, and the Medical Records Coordinator at 4:25 PM, revealed they were trained on how to check the side rails to ensure they were not loose and working properly. The staff also stated they were required to perform return demonstrations. 10. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM revealed all the staff were trained on the Decision Guide and screening new admissions for the appropriateness of side rails. Interview with the Maintenance Director on [DATE] at 2:35 PM revealed that if a staff member other than himself installed a side rail on a bed, he would follow up the next business day to ensure proper installation of the side rails. 11. Review of a sign-in sheet and interview with the DON on [DATE] at 11:45 AM revealed she was trained by the sister facility's MDS Coordinator on developing and implementing side rail care plans for residents utilizing side rails, with specific monitoring requirements for the side rails. 12. Review of a care plan checklist and interview with the MDS Coordinator on [DATE] at 3:43 PM, revealed from [DATE] through [DATE], all care plans were reviewed to ensure the appropriate side rail status was correct for the resident. 13. Review of care plans for Resident #3, Resident #4, and Resident #5 revealed they were updated to reflect the correct size of side rail being utilized and to ensure the resident's Side Rail Assessment had been completed. Interviews on [DATE], at 4:25 PM with the Medical Records Coordinator and at 3:43 PM with the MDS Coordinator, revealed all resident care plans were updated to include the correct side rail and the risks associated with side rail usage for the resident. 14. Review of sign-in sheets dated [DATE] and [DATE] revealed the DON trained all nurses on care plan updates and the use of side rails, the risks of side rails for residents, and when side rail updates need to be completed. Staff were also required to complete a post-test. Interviews on [DATE], with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed staff were trained on updating care plans related to the use of side rails. 15. Review of a sign-in sheet dated [DATE] and interviews on [DATE], with the sister facility's DON at 10:25 AM, the DON at 11:45 AM, and the Medical Records Coordinator at 4:25 PM, revealed the DON and Medical Records Coordinator were trained by the sister facility's DON on obtaining appropriate physician orders [REDACTED]. Review of an audit form revealed physician orders [REDACTED]. 17. Review of sign-in sheets dated [DATE] and [DATE] and interviews on [DATE], with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed the nurses were trained by the DON on physician's orders [REDACTED]. 18. Review of a sign-in sheet dated [DATE] and interviews on [DATE], with the Medical Records Coordinator at 4:25 PM and the DON at 11:45 AM, revealed they were trained by the sister facility's Administrator on accurate documentation and documenting the correct time an event occurred on the nurse's note. 19. Observation of sign-in sheets dated [DATE] and [DATE] and interviews on [DATE], with SRNA #6 at 2:47 PM, SRNA #7 at 1:42 PM, SRNA #8 at 12:52 PM, LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed the staff had been trained on accurate and timely documentation. 20. Review of a facility roster dated [DATE], and interview with the Medical Records Coordinator on [DATE] at 4:25 PM, revealed she had reviewed all nursing entries for the last month to ensure appropriate documentation had been made. 21. Review of medical record audits dated [DATE] thru [DATE] and interview with the DON on [DATE] at 11:45 AM revealed she had been auditing medical records daily to ensure staff were documenting timely and accurately.

Based on interview, record review, and review of the facility's policy it was determined the facility failed to maintain complete, accurate medical records for one (1) of three (3) sampled residents (Resident #1). Review of Resident #1's Nurse's Notes dated [DATE] at 2:22 AM, revealed Registered Nurse (RN) #1 documented that the resident was resting well, eyes closed, respirations even and unlabored, denies pain, and vital signs stable. However, interview with RN #1 revealed she walked by Resident #1's room at approximately 2:00 AM on [DATE], but could not physically see the resident. At approximately 3:00 AM on [DATE], Resident #1 was found deceased , hanging off the side of the bed with his/her neck on the bed/side rail. The facility's failure to ensure medical records were accurate has caused or is likely to cause serious injury, harm, impairment, or death to a resident. Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835 and F842). The facility was notified of the Immediate Jeopardy on [DATE]. An acceptable Allegation of Compliance was received on [DATE], which alleged removal of the Immediate Jeopardy on [DATE]. The State Survey Agency determined the Immediate Jeopardy was removed as alleged on [DATE], prior to exit on [DATE], which lowered the scope and severity to D level at 42 CFR 483.21 Comprehensive Person-Centered Care Plans (F656), 42 CFR 483.25 Quality of Care (F700), and 42 CFR 483.70 Administration (F835 and F842) while the facility monitors the effectiveness of systemic changes and quality assurance activities. The findings include: Review of the facility's policy titled, Documentation in Medical Record, revised [DATE], revealed each resident's medical record shall contain an accurate representation of the actual experiences of the resident, and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Review of Resident #1's medical record revealed the facility admitted the resident on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was ten (10), indicating the resident was moderately cognitively impaired. Further review of the MDS revealed Resident #1 required the assistance of two (2) staff members for bed mobility and was totally dependent for transfers. Review of Resident #1's Nurse's Notes dated [DATE] at 2:22 AM, revealed Registered Nurse (RN) #1 documented that the resident was resting well, eyes closed, respirations even and unlabored, denies pain, and vital signs stable. However, interview with RN #1 on [DATE] at 5:37 PM revealed she walked by Resident #1's room at approximately 2:00 AM on [DATE], and could not physically see Resident #1. RN #1 stated, The curtain was drawn when I passed (Resident #1's) room, but I would have been able to see if (the resident) was on the floor and (he/she) was not. RN #1 further stated, I could not see if (Resident #1's) eyes were closed or if (his/her) respirations were even and non-labored, but I one hundred percent believe that Nurse's Note was correct. Interview with State Registered Nurse Aide (SRNA) #3 on [DATE] at 9:18 AM revealed Resident #1 liked his/her curtain pulled at night for privacy. She stated on the night of [DATE] staff were unable to see the resident from the doorway because Resident #1's curtain was pulled. Review of a Nurse's Note dated [DATE], at 3:15 AM revealed RN #1 documented that Resident #1 was found on the floor on his/her knees on the right side of the bed with his/her neck against the bed rail and unresponsive. The resident had no pulse or respirations. Further review of the Note revealed the resident was noted to have bruising and redness below left ear to mid-anterior neck with superficial skin tear left jaw one centimeter, superficial abrasion at mid-base of anterior neck. Large bruise right forearm four cm (centimeter) by three cm, abrasions to top of both knees 2.0 cm by 2.0 cm. Interview with the Director of Nursing (DON) on [DATE] at 12:25 PM revealed RN #1's note that was written on [DATE] at 2:22 AM was an inaccurate Nurse's Note. The DON stated RN #1 should have observed/assessed Resident #1 and documented the time that she actually saw the resident. Interview with the Administrator on [DATE] at 11:25 AM confirmed the Nurse's Note documented by RN #1 on [DATE] at 2:22 AM was not an accurate Nurse's Note because RN #1 did not see Resident #1 at that time. ****The facility alleged the following was implemented to remove Immediate Jeopardy on [DATE]: 1. On [DATE], the facility reviewed and revised the Side Rail Policy and Side Rail Assessment. The policy stated side rails would be used only as an enabler to improve resident function. The policy defined enabler as a voluntary device, which facilitates movement and promotes independence, comfort, and safety. A decision guide would be used to determine if the side rail functioned as an enabler. If it was determined that a side rail would not function as an enabler for a resident, alternatives to side rails would be evaluated. If it was determined the alternative did not meet the resident's need, the facility would take the following steps: [NAME] Document how the alternatives failed to meet the resident's needs. If there was no appropriate alternative, document the reason. B. Assess the resident for risk of entrapment, and other risks associated with the use of side rails. The following are examples of potential risks: i. Accident hazards (i.e., falls, entrapment, injuries sustained from attempts to climb over, around, between, or through the rails) ii. Barrier from safely getting out of bed iii. Physical restraint (i.e., hinders from independently getting out of bed or performing routine activities) iv. Decline in function, such as muscle functioning/balance v. Skin integrity issues vi. Decline in other areas of daily living, such as using the bathroom, continence, eating, hydration, walking, and mobility vii. Negative psychosocial outcomes, such as altered self-esteem, feelings of isolation, or agitation/anxiety C. Obtain informed consent from the resident or the resident's representative for the use of bed rails, prior to installation/use. D. Determine whether the side rail is a restraint. Side rails will be considered a physical restraint when they limit the resident's freedom of movement. In such cases, the facility shall follow procedures related to physical restraints. E. Document the medical diagnosis, condition, symptom, or functional reason for the use of the side rail. F. Obtain physician orders [REDACTED]. G. Reassessments will be conducted in accordance with the facility's assessment schedule, but not less than quarterly, upon a significant change in status, any physical decline, or a change in the type of bed/mattress/rail. H. At the time a resident is determined to meet the criteria for side rails, the device decision guide will be utilized to ensure the rail is an enabler. I. If at any time side rails are removed from a resident's bed the resident's family and physician will be notified. 2. On [DATE], the Director of Nursing (DON) from a sister facility trained the facility's Administrator, DON, Medical Records Coordinator, Unit Coordinator (UC), and Activity Director/Licensed Practical Nurse (LPN) on the use of the facility's new Side Rail Policy and Side Rail Assessment form. 3. On [DATE], the DON, Medical Records Coordinator, and Activity Director/Licensed Practical Nurse (LPN), completed side rail assessments on all residents. The facility removed twenty (20) side rails from residents' beds. Two (2) were removed due to non-use and eighteen (18) were removed after the facility determined the risks of using the side rails outweighed the benefit of the side rail. Ten (10) residents in the facility are utilizing side rails. The DON assessed all ten (10) residents utilizing side rails for safety and appropriate consent. The DON will continue to monitor each of the ten (10) residents' safety while in bed daily for a week, then weekly times four (4) weeks, then monthly for two (2) months, and quarterly thereafter through the facility's Quality Assurance Program. In addition, the DON will monitor the twenty (20) residents who had their side rails removed daily for seven (7) days, and weekly thereafter for a month, and quarterly thereafter to ensure each resident's safety after the removal of the side rails. 4. Beginning on [DATE], the Social Worker contacted all resident families to discuss each resident's current situation related to side rails. The facility obtained consents from each resident or resident representative for each resident who will be utilizing side rails. 5. On [DATE], the sister facility's Administrator met with the Maintenance Director and reviewed the manufacturer's recommendations for all side rails in use in the facility. 6. On [DATE], the Maintenance Director checked all residents' beds to ensure they were in proper working order. In addition, the Maintenance Director inspected all beds equipped with side rails to ensure the side rails were not loose and that they were installed and being maintained per the manufacturer's recommendations. 7. Beginning on [DATE], the DON and Infection Control Nurse conducted daily rounds to ensure residents utilizing side rails were positioned appropriately in the bed and away from the side rails. The monitoring will continue daily for a week, then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. If any concerns were identified the Administrator would be notified immediately. 8. On [DATE] and [DATE], the DON and the UC trained all staff nurses on the revised Side Rail Policy and Side Rail Assessment Form. 9. On [DATE] and [DATE], the Maintenance Director trained the DON, UC, Infection Control Nurse, Administrator, Activity Director, and Medical Records Coordinator on how to appropriately install and remove side rails and how to check the side rails to ensure they were not loose and were properly installed. 10. Beginning on [DATE], the facility will screen all new admissions utilizing the facility's Side Rail Policy and Side Rail Assessment. Any residents admitted to the facility after normal business hours will have the assessment completed by the staff nurse assigned to the resident. The Therapy Department will then evaluate the resident for side rail usage. If Therapy deemed the resident appropriate for side rails, the staff will utilize the decision guide to ensure the side rails will act as an enabler for the resident. If a member of the nursing staff applies side rails to a new resident's bed upon admission, consent will first be obtained from the resident/resident's representative. The Maintenance Director will follow up the next business day to ensure the side rails were installed properly and presents no risk of injury to the resident. 11. On [DATE], the sister facility's Minimum Data Set (MDS) Coordinator trained the DON on developing an appropriate care plan for residents who utilize side rails and how to monitor the use of the side rail to ensure resident safety. 12. From [DATE] through [DATE], the MDS Nurse reviewed all resident care plans to ensure they reflected the resident's appropriate side rail status. The care plans were updated to include the appropriate use of side rails and specific monitoring of side rail use. 13. Beginning on [DATE], the Medical Records Coordinator and the MDS Assistant will review the side rail care plans for all residents utilizing side rails daily for seven (7) days to ensure no changes are needed and that the resident still meets criteria per the side rail policy. Reviews will continue daily for a week and then weekly for four (4) weeks, then monthly for two (2) months, and then quarterly thereafter. Any identified concerns will be reported to the Administrator immediately. 14. On [DATE], the DON trained facility nurses on updating and developing care plans for residents who utilize side rails. The care plan will include the resident's risks associated with the use of side rails and when care plans need to be updated related to side rails. 15. On [DATE], the sister facility's DON trained the DON and Medical Records Coordinator on obtaining appropriate physician orders [REDACTED]. Physician orders [REDACTED]. 16. On [DATE], the Medical Records Coordinator reviewed all physician's orders [REDACTED]. No concerns were identified. 17. On [DATE] and [DATE], the DON trained all nurses on obtaining appropriate physician orders [REDACTED]. 18. On [DATE], the sister facility's Administrator trained the Medical Records Coordinator and DON on accurate charting and ensuring observations and assessments were accurately documented at the time they were made. 19. On [DATE] and [DATE], the DON trained all Certified Nursing Assistants (CNAs) and licensed nurses on the accuracy of documentation, and making sure the documentation reflected the accurate time an event occurred. 20. On [DATE], the Medical Records Coordinator reviewed all medical records to ensure any new orders or resident events occurring in the last month were documented appropriately and were accurate. 21. Beginning on [DATE], the DON will review the twenty-four-hour report form daily and then compare that documentation to the resident's medical record to ensure all events were documented accurately and timely. Any identified concerns will be reported to the Administrator immediately. ***The State Survey Agency verified that the facility implemented the following action and that Immediate Jeopardy was removed on [DATE], as alleged by the facility: 1. Review of the facility's Side Rail Policy and Side Rail Assessment Form revealed it was revised as of [DATE]. Interview with the sister facility's DON on [DATE] at 10:25 AM, revealed the policy and assessment were revised to include all required components for ensuring residents were assessed appropriately for side rail use and that any use of side rails in the facility would be monitored for safety and appropriate functioning. 2. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, the UC at 12:27 PM, and the Activity Director at 3:22 PM, revealed a sister facility's Director of Nursing (DON) trained the staff on how to use the facility's revised Side Rail Policy and Side Rail Assessment Form. 3. Review of Side Rail Assessment Form screenings dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, the Medical Records Coordinator at 4:25 PM, and the Activity Director at 3:23 PM, revealed all residents were screened for the use of side rails. In addition, review of the Side Rail Audits dated [DATE] thru [DATE], revealed the DON had monitored the residents who had their side rails removed daily. Interview with the DON on [DATE] at 11:45 AM, revealed she had been monitoring the residents who had their side rails removed. Review of the medical records of the ten (10) residents who had their side rails removed revealed the residents' families and physicians were notified. Interview with Family Member #3 on [DATE] at 9:50 AM, revealed he/she was notified that his/her spouse's side rails were removed from the bed. Further interview revealed the facility explained the risk of side rails, and supplied the resident with a wing mattress. 4. Review of Safety Consents dated [DATE] revealed beginning on [DATE], the Social Worker contacted residents' families to discuss the resident's current side rail usage. All residents deemed to need the side rails had consent form acknowledgements signed by the resident or the resident's Responsible Party. 5. Review of a sign-in sheet dated [DATE], and interview with the Maintenance Director on [DATE] at 2:35 PM, revealed the Maintenance Director was trained by the sister facility's Administrator on the manufacturer's recommendations for all side rails utilized in the facility. 6. Review of Bed Check Audits and interview with the Maintenance Director on [DATE] at 2:35 PM, revealed he conducted a check of all resident beds on [DATE] to ensure the beds were working properly. Beds equipped with side rails were also checked to ensure the side rails were not loose and were installed per manufacturer's recommendations. 7. Review of Bed Check Audits completed [DATE] thru [DATE], and interviews on [DATE], with the DON at 11:45 AM and the Infection Control Nurse at 2:55 PM, revealed the DON and the Infection Control Nurse monitored daily to ensure side rails were in place for those residents who utilize them, and that they were an enabler for the resident, and that the residents were positioned appropriately in the bed away from the rails. 8. Review of sign-in sheets dated [DATE] and [DATE], and interviews on [DATE] with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed nursing staff were trained on using the revised Side Rail Policy and Side Rail Assessment Form. 9. Review of sign-in sheets dated [DATE] and [DATE], and interviews on [DATE] with the DON at 11:45 AM, the UC at 12:27 PM, the Infection Control Nurse at 2:55 PM, the Administrator at 10:50 AM, the Activity Director at 3:23 PM, and the Medical Records Coordinator at 4:25 PM, revealed they were trained on how to check the side rails to ensure they were not loose and working properly. The staff also stated they were required to perform return demonstrations. 10. Review of a sign-in sheet dated [DATE], and interviews on [DATE] with the DON at 11:45 AM, LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM revealed all the staff were trained on the Decision Guide and screening new admissions for the appropriateness of side rails. Interview with the Maintenance Director on [DATE] at 2:35 PM revealed that if a staff member other than himself installed a side rail on a bed, he would follow up the next business day to ensure proper installation of the side rails. 11. Review of a sign-in sheet and interview with the DON on [DATE] at 11:45 AM revealed she was trained by the sister facility's MDS Coordinator on developing and implementing side rail care plans for residents utilizing side rails, with specific monitoring requirements for the side rails. 12. Review of a care plan checklist and interview with the MDS Coordinator on [DATE] at 3:43 PM, revealed from [DATE] through [DATE], all care plans were reviewed to ensure the appropriate side rail status was correct for the resident. 13. Review of care plans for Resident #3, Resident #4, and Resident #5 revealed they were updated to reflect the correct size of side rail being utilized and to ensure the resident's Side Rail Assessment had been completed. Interviews on [DATE], at 4:25 PM with the Medical Records Coordinator and at 3:43 PM with the MDS Coordinator, revealed all resident care plans were updated to include the correct side rail and the risks associated with side rail usage for the resident. 14. Review of sign-in sheets dated [DATE] and [DATE] revealed the DON trained all nurses on care plan updates and the use of side rails, the risks of side rails for residents, and when side rail updates need to be completed. Staff were also required to complete a post-test. Interviews on [DATE], with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed staff were trained on updating care plans related to the use of side rails. 15. Review of a sign-in sheet dated [DATE] and interviews on [DATE], with the sister facility's DON at 10:25 AM, the DON at 11:45 AM, and the Medical Records Coordinator at 4:25 PM, revealed the DON and Medical Records Coordinator were trained by the sister facility's DON on obtaining appropriate physician orders [REDACTED]. Review of an audit form revealed physician orders [REDACTED]. 17. Review of sign-in sheets dated [DATE] and [DATE] and interviews on [DATE], with LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed the nurses were trained by the DON on physician's orders [REDACTED]. 18. Review of a sign-in sheet dated [DATE] and interviews on [DATE], with the Medical Records Coordinator at 4:25 PM and the DON at 11:45 AM, revealed they were trained by the sister facility's Administrator on accurate documentation and documenting the correct time an event occurred on the nurse's note. 19. Observation of sign-in sheets dated [DATE] and [DATE] and interviews on [DATE], with SRNA #6 at 2:47 PM, SRNA #7 at 1:42 PM, SRNA #8 at 12:52 PM, LPN #1 at 2:22 PM, LPN #2 at 1:30 PM, and LPN #3 at 1:15 PM, revealed the staff had been trained on accurate and timely documentation. 20. Review of a facility roster dated [DATE], and interview with the Medical Records Coordinator on [DATE] at 4:25 PM, revealed she had reviewed all nursing entries for the last month to ensure appropriate documentation had been made. 21. Review of medical record audits dated [DATE] thru [DATE] and interview with the DON on [DATE] at 11:45 AM revealed she had been auditing medical records daily to ensure staff were documenting timely and accurately.

Based on observation, interview, and review of the facility policy, it was determined the facility failed to ensure food was palatable related to seasoning of the food. Six (6) residents in the Resident Council Meeting conducted at 9:30 AM on 02/20/19 complained that the food tasted like the facility had opened the can, heated, and served the food. The findings include: Review of the facility policy titled Food Preparation Guidelines, revised 10/01/18, revealed the facility would provide palatable food to include using spices or herbs to season food in accordance with recipes. In addition, the facility would honor resident preferences, as possible, regarding food and drinks. Observation at 11:48 AM on 02/20/19 of a test tray revealed there was no seasoning in the regular and pureed green beans. The Administrator accompanied the surveyor with the palatability test. The Administrator agreed that the green beans (regular and pureed) tasted like the can had been opened, heated, and served. Interview with the Dietary Manager (DM) at 11:53 AM on 02/20/19 revealed the facility did not season the food because of the No Added Salt (NAS) diets. The DM stated she did not realize they could add seasoning to the food during the cooking process for the NAS diets.

Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure a person-centered plan of care related to respiratory therapy was implemented for one (1) of twenty-six (26) sampled residents (Resident #35). Review of the care plan revealed an intervention for Resident #35 to get oxygen as ordered by the physician. Review of the physician orders [REDACTED].#35 on 02/19/19, 02/20/19, and 02/21/19 revealed Resident #35 did not receive the physician-ordered oxygen flow rate. The findings include: Review of the facility's policy, Care Plan Interdisciplinary, dated 10/01/07 and reviewed on 10/01/18, revealed an individualized care plan would be developed for all residents admitted to the facility. The policy stated an updated and current individualized care plan was necessary to ensure each resident received the nursing care needed to treat identified problems that were specific to each resident. According to the policy, the care plan process would use the usual format: assess, plan, implement, evaluate, and reassess. Further review revealed the care plan was written using information from the Care Area Assessments (CAAs) as a guide to drive the care plan. Further review of the policy revealed an individualized plan would be developed on all residents admitted to the facility. Review of Resident #35's medical record revealed the facility admitted the resident on 01/26/19 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's Brief Interview for Mental Status (BIMS) score was thirteen (13), indicating the resident's cognition was intact. Review of Resident #35's physician orders [REDACTED]. Review of the comprehensive plan of care (undated) revealed an intervention to give oxygen therapy as ordered and to monitor pulse oximetry and vital signs. Observation of Resident #35 on 02/19/19 at 4:03 PM, revealed the resident was receiving oxygen at two (2) liters per minute (LPM) via nasal cannula. Further observation on 02/20/19 at 10:45 AM and 11:00 AM, and on 02/21/19 at 8:21 AM, revealed the resident was receiving oxygen at 2.5 LPM via nasal cannula. Review of Resident #35's weekly oxygen saturation readings for 02/19/19 and 02/20/19 revealed the resident's oxygen saturation averaged 96%. Interview with Resident #35 on 02/19/19 at 4:05 PM revealed he/she utilized three (3) liters of oxygen at home. The resident stated he/she had never adjusted the oxygen settings at the facility. Observation and interview with Licensed Practical Nurse (LPN) #2 on 02/21/19 at 9:03 AM revealed the LPN confirmed Resident #35's oxygen was set to 2.5 LPM. Interview with the nurse revealed she was responsible for the resident's care that day and on 02/20/19. Further interview revealed she was responsible for ensuring the resident was receiving oxygen at the physician-ordered flow rate every shift, and stated the flow rate should have been set to three (3) LPM. A telephone interview conducted with LPN #1 on 02/21/19 at 10:39 AM revealed she was the nurse responsible for Resident #35's care on 02/19/19. LPN #1 stated she was not aware the resident's oxygen was set on two (2) LPM on 02/19/19. She stated she checked the resident's oxygen saturation at least once per shift and no concerns were identified. Interview with the Director of Nursing (DON) on 02/21/19 at 4:19 PM, revealed nurses were required to assess each resident's oxygen flow rate and review their plan of care every shift to ensure the resident was receiving the physician-ordered amount of oxygen. Further interview revealed she was not aware that Resident #35 was not receiving oxygen as ordered by the physician.

Based on observation, interview, medical record review, and review of the facility's policy, it was determined the facility failed to ensure one (1) of twenty-six (26) sampled residents (Resident #35) received respiratory care (oxygen therapy) according to the physician's orders [REDACTED]. Resident #35 had physician's orders [REDACTED].#35's oxygen as ordered. The findings include: Review of the facility's oxygen policy titled Oxygen and General Nursing, dated 10/01/07 (with a reviewed date of 10/01/18), revealed only licensed nurses and respiratory therapists were authorized to make changes in residents' oxygen administration and should instruct other staff not to change the oxygen flow rate. Review of Resident #35's medical record revealed he/she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #35's brief interview for mental status (BIMS) score was thirteen (13) indicating his/her cognition was intact. Review of Resident #35's physician orders [REDACTED]. Observation of Resident #35 on 02/19/19 at 4:03 PM, revealed the resident was receiving oxygen at two (2) LPM via nasal cannula; on 02/20/19 at 10:45 AM and 11:00 AM, the resident was receiving oxygen at 2.5 LPM via nasal cannula, and on 02/21/19 at 8:21 AM, the resident was receiving oxygen at 2.5 LPM via nasal cannula. Review of weekly oxygen saturation readings for 02/19/19 and 02/20/19 revealed the resident's oxygen saturation averaged 96%. Interview with Resident #35 on 02/19/19 at 4:05 PM revealed he/she wore oxygen at home prior to coming to the facility and the liter flow was on three (3) LPM. Further interview with Resident #35 revealed he/she never adjusted the oxygen settings. Observation and interview with Licensed Practical Nurse (LPN) #2 on 02/21/19 at 9:03 AM revealed the oxygen was set on 2.5 LPM. Further interview revealed the nurse was responsible to check Resident #35's oxygen flow regulator to ensure the resident was receiving the physician-ordered flow rate every shift. Continued interview revealed she confirmed the resident should be receiving oxygen at the physician-ordered rate of three (3) LPM. Additional interview revealed she was responsible for Resident #35 on 02/20/19 and 02/21/19. A telephone interview conducted with LPN #1 on 02/21/19 at 10:39 AM revealed she was the nurse responsible for Resident #35 on 02/19/19 and she was not aware the oxygen was on two (2) LPM. Further interview revealed she checked the oxygen saturations at least once per shift. Interview with the Director of Nursing (DON) on 02/21/19 at 4:19 PM, revealed nurses were required to assess each resident's oxygen flow rate every shift to ensure the resident was receiving the physician-ordered amount of oxygen. Further interview revealed she was not aware Resident #35 was not receiving the physician-ordered oxygen flow rate.

Based on interview, record review, review of the facility investigation, and review of the facility policy it was determined the facility failed to protect the right to privacy for one (1) of three (3) sampled residents (Resident #1). Interviews with staff revealed approximately one month ago, State Registered Nurse Aide (SRNA) #1 shared a video and photographs of Resident #1 on a social media group message that included other staff members. The findings include: Review of the facility's Resident Rights policy, last reviewed 10/01/18, and the attached Resident's Rights-Federal Law revealed the resident had a right to a dignified existence and the facility must protect the rights of each resident including the right to personal privacy including personal care. The policy further stated the facility would ensure that all staff members were educated on the rights of residents and the responsibility of the facility to properly care for its residents. Review of Resident #1's medical record revealed the facility admitted the resident on 11/29/17 with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score was three (3), which indicated the resident was not interviewable. Interview with Resident #1 on 12/19/18 at 1:15 PM revealed the resident denied any concerns with staff treatment or his/her rights at the facility. Interview with SRNA #3 on 12/19/18 at 2:15 PM revealed SRNA #1 was present when SRNA #3 painted Resident #1's fingernails approximately one (1) month ago. SRNA #3 stated that after they exited the resident's room SRNA #1 showed her a video that she had on her phone of SRNA #3 painting the resident's nails. SRNA #3 stated SRNA #1 then sent the video to a group chat. SRNA #3 stated Resident #1's face was visible in the video. Interview with SRNA #4 on 12/19/18 at 2:00 PM and SRNA #2 on 12/19/18 at 3:50 PM revealed they had received a video and photographs of Resident #1, via a social media group message approximately a month ago. The SRNAs stated the resident's face was visible in the pictures and the video. SRNA #2 stated that SRNA #1 sent the message with the video/photographs. Interview with SRNA #1 on 12/19/18 at 2:35 PM revealed she had recorded a video of another staff member painting Resident #1's fingernails. She stated she had sent the video via social media to a group chat but stated the video had no identifying images of the resident and only included the resident's hands. SRNA #1 denied taking any other photographs of Resident #1 or sending any identifying images of the resident via social media. Interview with the Administrator on 12/19/18 at 4:15 PM revealed she was notified on 12/04/18 of a video being shared to a social media group message. She stated that through her investigation she identified that the video, which included identifying images of Resident #1, had been initially shared approximately one (1) month prior to her becoming aware of the alleged violation. She also stated that staff should have reported the sharing of videos/photographs of a facility resident on social media immediately when it occurred.

Based on observation, interview, and record review, it was determined the facility failed to post the nurse staffing data daily at the beginning of each shift. Observation on 12/12/17, and review of staffing data that was posted from 06/19/16 through 12/11/17, revealed the facility failed to post the actual hours that licensed and unlicensed nursing staff worked each shift. In addition, the facility failed to maintain twenty-four (24) daily staffing schedules for the previous eighteen (18) months. The findings include: Interview with the Director of Nursing (DON) on 12/14/17 at 4:37 PM revealed the facility did not have a policy that addressed posting of licensed and unlicensed nursing staff at the facility. Observation on 12/12/17 at 11:42 AM revealed the facility posted the number of nursing staff that were present for the day, evening, and night shift on 12/12/17; however, the total number of actual hours worked were not completed for each shift. Review of the eighteen (18) months of staffing posted revealed the nurse staffing data that was posted from 06/19/16 through 12/12/17 did not show the actual hours worked for licensed and unlicensed staff. Staffing schedules were missing for the following dates: 08/02/16, 08/03/16, 08/04/16, 09/03/16, 09/17/16, 10/09/16, 11/22/16, 11/27/16, 12/16/16, 12/17/16, 12/18/16, 12/19/16, 03/10/17, 04/03/17, 04/04/17, 04/11/17, 04/13/17, 04/14/17, 04/26/17, 05/02/17, 05/12/17, 05/24/17, 05/27/17, and 07/31/17. Interview on 12/12/17 at 12:04 PM with the Director of Nursing (DON) revealed it was the night shift nurses' responsibility to post the 24-hour nurse staffing report. The DON stated that it was her responsibility to check the posting of staffing daily for accuracy, but she was not aware that the posting was required to show the actual hours worked. Interview with the Administrator on 12/12/17 at 12:31 PM revealed it was important to post staffing daily so that the visitors and family members could see that the facility was providing adequate staffing to care for the residents in the facility. The Administrator stated that she was not aware that the actual number of hours that staff worked must be posted daily.

Based on interview, record review, and review of the Resident Assessment Instrument (RAI) Version 3.0 User Manual, it was determined the facility failed to assure the accuracy and completion of Sections C and D of the Minimum Data Set (MDS) assessment for two (2) of twelve (12) sampled residents (Residents #38 and #34) and two unsampled residents (Residents #12 and #20). The findings include: Review of the MDS 3.0 Manual, Chapter 3, Page C-1, dated October 2017, revealed the intent of Section C: Cognitive Patterns was to determine the resident's attention, orientation, and the ability to recall new information. According to the manual, these items were crucial factors in care planning decisions, identifying needed supports, and identifying possible [MEDICAL CONDITION] behaviors. The manual stated that the interview items were to be conducted the day before or the day of the Assessment Reference Date (ARD). Review of Section D: Mood revealed the items in this section address mood distress, a serious condition that is underdiagnosed and undertreated in the nursing home and is associated with significant morbidity. It is particularly important to identify signs and symptoms of mood distress among nursing home residents because these signs and symptoms can be treatable. The manual also stated that most residents who are capable of communicating can answer questions about how they feel. Continued review of the MDS 3.0 User Manual revealed a dash value indicates that an item was not assessed. Review of a memo issued by The Centers for Medicare and Medicaid Services (CMS) in June 2011 addressing the use of dashes revealed, Inappropriate use of a dash (-) has implications for the accuracy of quality measures and for communicating resident status at discharge to support coordination and continuity of care. Review of the facility's policy titled Electronic MDS Record, dated 06/08/11, revealed the MDS Coordinator, Social Services, Dietary, and Activities staff would input their information into the electronic Minimum Data Set (MDS) record. 1. Review of the record for Resident #12 revealed the facility admitted the resident on 02/13/17 with [DIAGNOSES REDACTED]. Review of Resident #12's quarterly MDS assessment with an Assessment Reference Date of 10/06/17 revealed that interviews for Section C: Cognitive Patterns and Section D: Mood were not completed and dashes were documented in the item sets. 2. Review of the record for Resident #20 revealed the facility admitted the resident on 02/04/13 with [DIAGNOSES REDACTED]. Review of Resident #20's quarterly MDS assessment with an Assessment Reference Date of 10/06/17 revealed that Section C: Cognitive Patterns - Brief Interview for Mental Status (BIMS) and Section D: Mood interview had not been completed and dashes were documented in the assessment. 3. Review of the record for Resident #38 revealed the facility admitted the resident on 08/09/12 with [DIAGNOSES REDACTED]. Review of the resident's quarterly MDS assessment with an Assessment Reference Date of 08/18/17 revealed the facility documented dashes in the resident's assessment for Section C: Cognitive Patterns - Brief Interview for Mental Status (BIMS) and Section D: Mood interview and there was no evidence the interviews were completed. 4. Continued review of the Resident Assessment User Manual, revised October 2016, revealed the 30-day PPS assessment is required by Medicare and it authorizes payment for days thirty-one (31) thru sixty (60) of the Part A Medicare stay for nursing home facilities. Review of Resident #34's medical record revealed the facility admitted the resident on 10/31/17, following a hospitalization with [DIAGNOSES REDACTED]. Review of Resident #34's MDS assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status score of twelve (12), which indicated the resident was cognitively intact. Review of Resident #34's 30-day Prospective Payment System (PPS) MDS assessment dated [DATE], revealed Section C (cognitive pattern assessment) and Section D (mood assessment) were not completed. Interview with the MDS Coordinator on 12/14/17 at 4:06 PM revealed she provided a weekly schedule of residents who required an MDS assessment to each department and kept a copy of the notification. The MDS Coordinator provided a copy of the schedule for the week of 10/01-10/17 that was sent to facility staff to remind them that resident assessments were due. A review of the schedule revealed that Residents #12 and #20 were on the list for an assessment to be completed during that timeframe. The MDS Coordinator also provided a copy of the MDS schedule for 09/15-22/17, which revealed Resident #38 required an assessment to be completed. Further interview with the MDS Coordinator revealed she keeps copies of all notifications she sends to each department responsible for completing sections on the MDS. Continued interview revealed the MDS Coordinator was off work when Resident #34's 30-day PPS assessment was due (11/28/17) and could not speak to the timeliness of staff notification. Interview with the Social Worker on 12/14/17 at 3:45 PM revealed she was responsible to complete Sections C and D of each resident's MDS. Further interview with the Social Worker revealed she was not aware that the quarterly assessment for Residents #12, #20, and #38 needed to be completed until after the Assessment Reference Date passed. Further interview with the Social Worker revealed she documented that Sections C and D were not assessed but signed the MDS as completed. Interview with the Director of Nursing (DON) on 12/14/17 at 4:17 PM revealed each department was responsible for completing their assigned section of each resident MDS. The DON stated she was responsible for signing MDS assessments when they were completed but did not review them for accuracy.

Based on observation and interview, it was determined that the facility failed to properly label biologicals stored in one (1) of three (3) medication carts, the North Hall medication cart. A storage type container was observed in the medication cart that contained a white powdery substance. The facility failed to ensure the container was labeled to identify the contents, instructions, and expiration date. The findings include: A policy on medication labeling and storage was requested; however, the facility did not provide a policy. On 12/14/17 at 9:00 AM observation of the North Hall medication cart revealed a plastic container with a lid in the bottom drawer that contained a white powdery substance. The container was not labeled with the contents of the container. Interview with the Licensed Practical Nurse (LPN) revealed that the white substance was thickener. She stated that the container should have been labeled with the contents and dated. On 12/14/17 at 4:55 PM interview with the Director of Nursing revealed that the container should have been labeled.

Based on interview, record review, and a review of the facility's policy and procedures, it was determined the facility failed to use the results of the resident's comprehensive assessment to develop a care plan for (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 to require the assistance of two staff members for bathing and transferring. However, the facility failed to develop a care plan that reflected the resident's required assistance, and developed a care plan that stated that the resident only required the assistance of one staff member for bathing. On 08/13/17, State Registered Nurse Aide (SRNA) #1 assisted Resident #1 with transferring from the shower to a wheelchair, without the assistance of another staff member. Resident #1 became weak and the SRNA had to assist the resident to the floor. The resident developed pain and on 08/24/17 the resident was diagnosed with [REDACTED]. The findings include: Review of the facility's policy and procedure titled, Fall Prevention, reviewed on 09/23/16, revealed the facility would comprehensively assess all residents for the risk of falling in order to avoid injury related to falls. The policy stated that after the assessment the facility would implement personalized interventions based on each resident's needs. Record review revealed the facility admitted Resident #1 on 09/03/14, with [DIAGNOSES REDACTED]. Review of Resident #1's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1 to require extensive assistance of two (2) or more staff members for all transfers and the resident was totally dependent on two staff members for bathing. However, a review of Resident #1's Comprehensive Care Plan, last reviewed on 06/12/17, revealed the facility developed a care plan with an intervention for only one staff member to assist the resident with bathing. A review of a nursing progress note for 08/12/17 revealed Resident #1 was being transferred after a shower, and the resident became weak and staff assisted the resident to the floor. Interview with SRNA #1 on 10/25/17 at 2:00 PM and on 10/26/17 at 3:01 PM, revealed she was the only staff member assisting Resident #1 with a shower on 08/12/17, when the resident fell . SRNA #1 had assisted Resident #1 to stand and the SRNA was holding (the resident) up with my right leg/knee, holding the resident's gait belt with one hand, and reaching for the resident's wheelchair with the other hand, when the resident began to slide down the SRNA's leg. The SRNA stated she gently lowered Resident #1 to the floor and activated the alarm to obtain assistance. Interview with Licensed Practical Nurse (LPN) #1 on 10/25/17 at 2:53 PM revealed he was at the nurses' station and was alerted that Resident #1 had fallen. The LPN stated that upon entering the bathroom, Resident #1 was sitting on the floor. LPN #1 stated he assessed the resident and identified no injuries. However, a review of a nursing progress note dated 08/13/17 at 2:15 AM revealed the resident was transferred to the hospital due to pain. Review of the hospital discharge instructions dated 08/13/17 revealed Resident #1 had x-rays of the bones in the right leg that did not show a fracture, and the resident was diagnosed with [REDACTED].#1 was transferred back to the facility with a new order for [MEDICATION NAME] (a narcotic pain medication) every six (6) hours as needed for pain. Continued review of nursing progress notes dated 08/13/17 through 08/23/17 revealed the resident continued to complain of pain to the right knee/hip/thigh areas. Review of nursing notes and the resident's Medication Administration Record [REDACTED]. In addition, review of physician progress notes [REDACTED]. On 08/23/17, the progress note revealed the physician decided to obtain further tests due to the resident's pain. Review of Resident #1's x-ray results dated 08/24/17 revealed the resident had a mildly displaced [MEDICAL CONDITION] femur (bone in the upper leg). An interview with the MDS Coordinator on 10/25/17, at 3:30 PM revealed Resident #1's care plan was inaccurate and should have stated the resident required two staff members for bathing.

Based on observation, interview, record review, and a review of the facility's policy and procedures, it was determined the facility failed to provide supervision to prevent falls for one (1) of three (3) sampled residents (Resident #1). The facility assessed Resident #1 to require the assistance of two staff members for bathing. However, the facility developed a care plan for the resident that stated the resident only required the assistance of one staff member. On 08/13/17, State Registered Nurse Aide (SRNA) #1 assisted Resident #1 with transferring from the shower chair to a wheelchair, without the assistance of another staff member. Resident #1 became weak and was assisted to the floor. The resident developed pain and on 08/23/17, the resident was diagnosed with [REDACTED]. The findings include: Review of the facility's policy and procedure titled Fall Prevention, reviewed on 09/23/16, revealed the facility would comprehensively assess all residents for the risk of falling in order to avoid injury related to falls. The policy stated after the assessment the facility would implement personalized interventions based on each resident's needs. Observation and attempted interview with Resident #1 on 10/25/17 at 2:42 PM revealed the resident was in bed with closed eyes. Record review revealed the facility admitted Resident #1 on 09/03/14, with [DIAGNOSES REDACTED]. Review of an annual Minimum Data Set (MDS) assessment dated [DATE] revealed the facility assessed Resident #1's cognition as moderately impaired, with a Brief Interview for Mental Status (BIMS) score of seven (7). Further review revealed the facility assessed Resident #1 to require extensive assistance of two (2) or more staff members for all transfers and the resident was totally dependent on two staff members for bathing. However, a review of Resident #1's Comprehensive Care Plan, last reviewed on 06/12/17, revealed the facility developed a care plan for the resident that stated the resident only required the assistance of one staff member for bathing. A review of a nursing progress note for 08/12/17 revealed Resident #1 had a shower and was being transferred when the resident became weak and was assisted to the floor by a staff member. Interview with State Registered Nurse Aide (SRNA) #1 on 10/25/17 at 2:00 PM and on 10/26/17 at 3:01 PM revealed she was the only staff member assisting Resident #1 with a shower on 08/12/17 when the resident fell . SRNA #1 had assisted Resident #1 to stand and the SRNA was holding (the resident) up with my right leg/knee, holding the resident's gait belt with one hand, and reaching for the resident's wheelchair with the other hand when the resident began to slide down the SRNA's leg. The SRNA stated she gently lowered Resident #1 to the floor. SRNA #1 stated she activated the alarm to obtain assistance. Interview with LPN #1 on 10/25/17 at 2:53 PM revealed he was at the nurses' station and was alerted that Resident #1 had fallen. The LPN stated that upon entering the bathroom, Resident #1 was sitting on the floor. LPN #1 stated he assessed the resident and identified no injuries. However, a review of a nurse's note dated 08/13/17 at 2:15 AM revealed Resident #1 had pain in his/her right hip and thigh and was transferred to the hospital Emergency Department (ED) for evaluation. Review of the hospital discharge instructions dated 08/13/17 revealed Resident #1 was diagnosed with [REDACTED]. Review of a nursing progress note dated 08/14/17 at 11:22 AM, revealed Resident #1 continued to have pain and pain medication was administered. The nurse's note further stated Resident #1's physician was notified of Resident #1's increased pain. A review of a Physician's Progress Note dated 08/17/17 revealed the physician assessed the resident to have fluid on the knee and ordered physical therapy. The physician stated if there was no improvement in the resident he would consider doing an MRI. Continued review of nursing progress notes dated 08/18/17 through 08/21/17 revealed the resident continued to have pain in the right leg and staff administered pain medication. Review of a Physician's Progress Note dated 08/22/17 revealed Resident #1 continued to have a very painful right knee, but elected to continue with conservative therapy. Further review of physician progress notes [REDACTED]. Review of Resident #1's x-ray results dated 08/24/17 revealed the resident had a mildly displaced fracture of the distal femur (bone in the upper leg).